
Book .M3 



GopightN°_ 



CQEmmur deposit. 



/TV? 




Look out for an announcement of the "cure" some good morn- 
ing. Meantime put up the best fight you can, and don't worry 
over spilt milk; but don't spill any more! Read the following 
pages carefully and learn how to avoid it. Then keep this little 
volume handy to refresh your memory and jog your will-power. 
Yours for sticking to the cure, 

McD. McLean. 




Prof. Robt. Koch 

(See p. 92) 

Discoverer of the tubercle bacillus. 

(Courtesy Moffat, Yard & Co.) 



Dr. Trx*deau 
(See p. 133) 
Distinguished "T.B." and pioneer 
in open air and sanatorium treat- 
ment of tuberculosis. 
(Courtesy Doubledav Page & Co.) 




Tubercle Bacilli 

(See p. 18) 

The little red rods are the bacilli. 

(After Jagie & Barrensheen. Courtesv of Dr. L. F. Barker 

and D. Appleton & Co.) 



TUBERCULOSIS 

A 

Primer and Philosophy 

FOR 

Patient and Public 



McDugald McLean, B.A., B.Sc. (Oxford), 
M.D. (Johns Hopkins) 




JOURNAL OF OUTDOOR LIFE PUB. CO. 

370 Seventh Ave. 

New York 

1922 



»>^ 






Copyright 

McD. McLEAN 

1922 



©CU692296 



The Inland Press 
ashevtlle, n. c. 

DEC -7 '22 



To 
E. W. M. 

and 
S. W. M. 

"I marvel that God made you mine, 
For when He frowns 'tis then ye shine.' 



*^. CONTENTS %* 

PAGE 

Foreword -•- 9 

PART I 

CHAPTER 

I When and How We Get Our Infections 1 1 

II The Baccilus and the Lung _ 18 

III The Nature of the Disease 21 

IV Danger Signals 25 

V Good and Bad Advice 31 

VI Morale '. 39 

VII Prevention and Cure 45 

VIII Climate and Altitude 58 

IX Helpful Suggestions 66 

X Miscellaneous 77 

PART II 

CHAPTER 

I Historical 89 

II Physician and Patient 99 

III Phthisiophobia and the Careless Con- 

sumptive Ill 

IV Health vs. Patent Medicines, Char- 

latans, and Christian Science 113 

V Temperaments and Tuberculosis 123 

VI Distinguished "T. B'S" 133 

Appendix 152 

Index 166 



w* FOREWORD t&* 

The purpose of this little volume is to give the 
patient something that will interest and encourage 
him, and at the same time include such general in- 
formation as he and the public should have — a sum- 
mary of the best opinion and advice of our leading 
specialists, digested by six years of experience as a 
patient and assistant, and a careful study of the cur- 
rent literature and standard texts on the subject. 

In no sense is it intended to take the place of the 
doctor. It would be disastrous to give the patient any 
set of rules and let him attempt to direct his own 
case. There are three things in the treatment of 
tuberculosis : Rest, Morale and Advice — and the last 
should be first. Without it the patient is like a 
mariner without a compass, a blind man trying to 
cross Broadway at 42nd Street. If the reader gets 
the idea from these pages that the first duty of a 
"t. b.," and the safest and cheapest course, is to seek 
the advice and direction of a competent specialist this 
little book will be amply justified. 

My experience with tuberculosis has been varied, 
and has extended over a period of six years now, and 
into California, New Mexico, New York and Ashe- 
ville. During this time I have had ample leisure to 
meditate upon tuberculosis from the viewpoint of a 
patient and a doctor, and to witness the ebb and flow 
of individual and sanatorium morale, the tragedies 



FOREWORD 

and the triumphs in the chase of the cure, and to take 
part in that life both as a patient and as an assistant 
in the sanatorium. In Part II I have recorded some 
observations and reflections from these experiences. 

I hope that this little volume may be of some 
practical help and encouragement to the many 
patients going through "the course," and that it may 
help to spread the information that is necessary for 
the prevention of this disease. When every one is 
thoroughly awake to the situation that tuberculosis 
can be more EASILY and SUCCESSFULLY and 
CHEAPLY PREVENTED than CURED a big ad- 
vance toward this end will have been made. 
McD. McLean, 

Asheville, N. C. 




PART I 
A PRIMER OF TUBERCULOSIS 



V5*. I ^r*> 

WHEN AND HOW WE GET OUR 
INFECTIONS 

"Keep out of indoors." 

— Koons. 

When. A summary of the best evidence on the 
infection with tubercle bacilli indicates that about 
75% of people who have reached the age of fifteen 
years have been infected. This does not mean that 
75% have been sick in bed with tuberculosis. A 
large majority of this 75% are entirely unaware of 
such infection, which is revealed only by a positive 
tuberculin reaction. Practically 100% of those who 
live to be thirty years old receive such infection. In 
the first year of life positive tuberculin reactions are 
found in about 9%, by the fifth year in about 45%, 
by the tenth year in about 66 % , and by the fifteenth 
year in about 75%. These figures are based on city 
inhabitants and largely the poorer classes. They 
would undoubtedly be lower for the better classes and 
rural population. 

Infection and Disease. It is, perhaps, well to 
point out here the difference between infection with 
tubercle bacilli and the clinical disease tuberculosis. 
The former may occur without producing symptoms 
sufficient for the one affected to be aware of it, and 

11 



TUBERCULOSIS 

the infection may be so successfully overcome that it 
will never cause any trouble. By clinical tuberculosis 
is meant the disease with manifest symptoms of fever, 
cough, loss of appetite and weight, etc. 

Most Dangerous Period. A large majority of 
people who break down with clinical tuberculosis do 
so between the ages of eighteen to thirty years. A 
sharp rise in the mortality from tuberculosis occurs 
at the age of puberty. That this new physiological 
strain is a factor is indicated by the fact that the rise 
occurs earlier in girls than in boys, corresponding 
with puberty in the two sexes. The period from 18 to 
30 years is one of strenuous life, dissipation and ex- 
cesses in various forms, physical and mental over- 
strain in beginning business and professional careers, 
and worry over initial failures. It is this physio- 
logical and physical strain and mental stress and 
anxiety that cause so many breakdowns during this 
period of life, when resistance is lowered and the old 
foci of infection are fanned into activity by these 
unusual hardships. 

Tuberculosis is a very deadly disease in infants. 
While only about 15% react postively to tuberculin 
in the first two years of life, the mortality rate is so 
high (75 to 80%) that the actual number of deaths 
equals, or exceeds, that of any other year of life. In 
adults positive tuberculin reactions are found in 75 to 
100%, but the mortality rate has dropped to about 
25%. There is a sharp fall in the annual death rate 
with the third year of life and it continues to fall till 



12 



INFECTIONS 

about the fifteenth year, when there is a sharp rise at 
the age of puberty. This rise continues to about the 
twentieth year when the number of deaths again 
equals that of the first two years. From the twentieth 
to the forty-fifth year the annual rate is high and 
about equal to that of the first two years. From the 
third to the twentieth year the average rate is about 
one-third that of the first two years and that of the 
twentieth to forty-fifth years. 

How. Infection takes place through exposure to 
tubercle bacilli. The bacilli gain entrance into our 
bodies : 

(a) By breathing air which has been contami- 
nated by the spray from coughing and sneezing of 
tuberculous patients, and from the dust of dried 
tuberculous sputum. 

(b) By drinking infected milk and eating in- 
fected food. The milk may come from a tuberculous 
cow, or it may be infected from outside sources, as 
food is, by flies, dirty fingers, coughing over it, etc. 

(c) Other sources of infection such as inoculation 
through abrasions of the skin and wounds are 
probably responsible for a small percentage of cases. 

It is estimated that about 92% of the infections 
come from man to man, and about 8% from tuber- 
culous cows. 

Primary Infection. Primary infection from the 
gastro-intestinal tract is estimated to occur in as high 
as 25% of cases. About half of the infections from 
the intestinal tract are caused by the bovine bacillus 

13 



TUBERCULOSIS 

and about half by the human bacillus. Inhalation 
infection probably accounts for most of the remaining 
cases, although recent investigations indicate that the 
ingestion method and inoculation through abrasions 
of the skin are probably more frequent sources than 
generally considered. 

Congenital Infection and Heredity. Congenital 
infection is very rare, and comes from the mother 
through a tuberculous placenta. Tuberculosis is not 
inherited. There is no evidence that it comes from 
the germ plasm, or is transmitted from the father. 
On the contrary, there is good evidence that children 
of tuberculous parents inherit an increased resistance 
to infection, as far as any specific inheritance is con- 
cerned. One will naturally ask then, why do children 
from tuberculous families develop tuberculosis more 
often than those from non-tuberculous families ? The 
answer is because they are much more frequently and 
constantly exposed to infection by careless and 
ignorant parents and sibs. 

No Absolute Immunity. There is no absolute 
immunity to tuberculosis in man, although a relative 
racial immunity seems to be well established, espe- 
cially among the Jews, and other white civilized races 
that have been in contact with it for many centuries. 

It is now established that the first seat of disease 
is in the lymphatic glands, where the bacilli may lie 
for many years. If the number and virulence of the 
bacilli are sufficiently great, or if the resisting power 
is unusually low, disease may follow infection in a 

14 



INFECTIONS 

short time; otherwise, complete healing may take 
place without the development of any recognizable 
symptoms. 

Local Disposition and Constitutional Predisposi- 
tion. Certain factors and diseases render the lungs 
and various organs and parts of the body more sus- 
ceptible to the development and spread of tuberculosis 
in them, and they are included in the term "local 
disposition." Chief among such factors are: (1) 
prolonged physical and mental over-strain, (2) 
under-nutrition and unhygienic surroundings — long 
residence in poorly ventilated quarters greatly lowers 
resistance, (3) measles, whooping cough, and in- 
fluenza, (4) diabetes, (5) pregnancy. 

A constitutional predisposition or tendency to 
develop tuberculosis in certain types of individuals 
and families has been noted for centuries. The indi- 
vidual with the "habitus phthisicus" is described as 
pale, thin and feeble, with frail bony framework, 
long, narrow and flat chest with wide intercostal 
spaces, and a small heart and aorta. Such a person, 
however, is prone to develop not only tuberculosis, 
but also any other infectious disease to which he is 
exposed. The inheritance of such nutritional faults 
and malformation of the bony framework and poor 
development of the heart and blood-vessels cannot be 
considered as a specific inheritance of a tendency to 
tuberculosis any more than a tendency to various other 
infections. And there is no conclusive evidence that 



15 



TUBERCULOSIS 

children of tuberculous parents inherit the "habitus 
phthisicus" in a higher percentage than children of 
non-tuberculous parents. 

Exposure to Infection. It is probable that in- 
fection rarely, or never, occurs in the open, hence 
tuberculosis has been aptly called a "house disease." 
Frequent contact, on the part of children, with tuber- 
culous persons who are careless in their habits and 
toilet, and who live in unhygienic quarters, leads to 
multiple re-infections and is of great importance in 
the development of the disease. It is doubtful, how- 
ever, that this is an important factor in adults. 
Doctors, nurses, and attendants at tuberculosis sana- 
toria do not develop tuberculosis any more frequently 
than they do in other fields of activity. An extensive 
investigation of married couples, where one of the 
partners is tuberculous, revealed the fact that the 
other one does not develop tuberculosis in a higher 
percentage than the general population (or at most 
very slightly higher) . Clinical tuberculosis in adults 
comes chiefly from an old focus of infection which is 
lighted up by some over-strain, malnutrition, or other 
infection. The fact that the great majority of our 
soldiers who developed tuberculosis did so within a 
month or two after entering upon active duties shows 
that old foci were fanned into activity rather than 
new infection acquired, for this is too short a time 
for new infection to reach the stage of clinical 
disease. 

16 



INFECTIONS 

Dr. E. R. Baldwin* summarizes present views 
on infection as follows: "The doctrine of inherited 
or acquired susceptibility is in doubt ... all 
infants are susceptible, and susceptibility lessens with 
increase in age; adults are comparatively insuscep- 
tible when without general or local lowered resistance 
and repeated or prolonged exposure. As to sources of 
infection . . . the sputum is of overwhelming 
importance . . . cow's milk is an important 
factor . . . mother's milk, the urine, feces, and 
other excretions of tuberculous invalids are not fre- 
quent sources of infection. As to means of trans- 
mission there is a growing belief in the importance of 
infected food, especially milk, for infants and 
children rather than for adults ; ... to adults 
dust and coughed spray are of more importance than 
infected food. . . . Pulmonary tuberculosis is 
often secondary to the lymphatic form (glandular) 

contracted in early life It is doubtful 

that a second infection from outside the body is a 
frequent occurrence after clinical healing of pul- 
monary tuberculosis in adults; ..." 



♦Modern Medicine, Osier and McCrae, Vol. I, p. 338. 

17 



*^. II %k*t 

THE BACILLUS AND THE LUNG 

"It is not what you have in your lungs 
but what you have in your head that deter- 
mines whether you will get well or not." 

— "San saying." 

The Tubercle Bacillus. The tubercle bacillus is 
a microscopic fungus, or plant, about one ten- 
thousandth to one five-thousandth of an inch long, 
and one-fifth to one- fourth as broad. It is rod shaped 
and motionless, and is a strict parasite, not having a 
habitat outside of man and animals, though it may 
exist for months in nature. It multiplies with great 
rapidity by dividing into two parts again and again, 
many millions being formed and expectorated daily, 
and produces poisons which kill the tissues around it. 
A healthy body is not favorable soil for the bacilli to 
grow in, but they may lie inactive in glands within 
the chest and in scar tissue surrounding old foci of 
infection for a long time (practically indefinitely) 
and then begin to multiply and grow again when by 
some chance such as prolonged over-strain, poor 
nutrition, etc., the tissues become favorable soil again. 
A striking peculiarity of this plant is the fact that 
light kills it. It can remain alive and virulent for 

18 



THE BACILLUS AND THE LUNG 

many months in darkness, dampness, dirt and cold, 
but it has not the "character" to endure exposure to 
light, and succumbs within a few minutes to a few 
days depending on the degree of light. 

Structure and Function of Lungs. In order to 
understand better the soil in which the bacilli grow I 
give a brief description of the structure and function 
of the lungs, the scene of activity in pulmonary 
tuberculosis. 

Man is endowed with a pair of lungs. The right 
one normally has three lobes and the left two, but the 
two lungs are about the same size and weight. They 
are covered by a thin tissue called the pleura which 
is reflected back over them from the chest wall which 
it also lines, and so forms a blind sac called the 
pleural cavity. The windpipe, or trachea, extends 
from the back of the throat down the middle of the 
chest and gives off a main branch, or bronchus, to 
each lung. These bronchi in turn give off many 
smaller bronchi, like the branches of a tree, and 
finally the innumerable smallest branches, called 
bronchioles, each terminate in a bunch of air cells, 
called a lobule, which is regarded as the unit of lung 
structure. These lobules are very tiny, about one two- 
hundredth of an inch in diameter, and there are 
millions of them. Their walls are composed of a 
very thin but tough layer of tissue, and are sur- 
rounded by a network of capillary blood vessels. 
Here the respiratory exchange takes place, when the 
oxygen of the inspired air is exchanged for the carbon 



19 



TUBERCULOSIS 

dioxide in the blood. This exchange takes place in 
accordance with the physical principle known as 
osmosis, i.e., the percolation and intermixture of gases 
or liquids through permeable walls. 

The normal individual inhales about one hundred 
and fifty gallons of air per hour, and the heart 
pumps about a hundred gallons of blood through the 
lungs in the same length of time — a marvelous per- 
formance and mechanism which deserves far more 
consideration than usually accorded it, especially 
when handicapped by tuberculosis ! 



20 



*^. Ill "fer* 

THE NATURE OF THE DISEASE 

"So gird up your hopes — 
He loses who mopes." 

— Forbes. 

Tuberculosis differs from most other infectious 
diseases, such as small-pox, typhoid fever, pneu- 
monia, etc., in that these diseases run a definite and 
limited course, usually a few weeks, and then the 
patient is either well or has begun a new life in the 
next world. Not so though with tuberculosis! The 
tubercle bacilli are able to live in our tissues in- 
definitely, and when the chance comes, to spread to 
other tissues and organs and set up clinical tuber- 
culosis. 

When infection occurs in the lung tiny little 
nodules, or tubercles, appear which consist of cheesy 
masses of dead tissue and bacilli. Surrounding the 
tubercle is a layer of cells thrown out by the body to 
protect itself from the invading germ. If the poisons 
produced by the germs are sufficient to kill these cells 
the disease spreads. Lung tissue thus destroyed is 
not replaced by lung tissue, but by scar tissue, which 
is the material used by nature in the repair of all 

21 



TUBERCULOSIS 

tissues. One may lose the use of five-sixths of the 
lung tissue and still live, such is the margin of safety 
with which we are endowed. 

Nature's Defense. — Nature attempts to isolate 
and wall off the bacilli and focus of infection as fol- 
lows. At first she throws an area of inn animation 
around the focus, as stated above, and this is later 
replaced by a wall of scar tissue which, if success- 
fully established, completely checks the disease and 
holds the bacilli under control. In some cases that 
do not advance very far the bacilli may be killed and 
the focus of infection absorbed, leaving only a tiny 
scar. In other cases nature desposits lime salts 
around the focus which later become calcined and 
form little stony walls about the focus, or replace it 
with stony formation, which Dr. Lawrason Brown 
has called the "grave-stones" of the dead bacilli. 

Slow Process. The formation of this scar tissue 
is a slow process, and this is why the tuberculous 
patient must be so careful about rest and exercise 
even many months after the cessation of such 
symptoms as fever and cough, as it requires at least 
a year or two for this scar tissue to become strong 
enough to withstand the ordinary strains of life put 
upon it. In the beginning the formation of this scar 
tissue is a spider web affair, or like the formation of 
ice upon a pond. If the patient has severe coughing 
spells, or exercises too much and thus increases the 
respirator}' movement and blood pressure, the fibrous 
tissue strands are broken and the formation of the 



22 



THE NATURE OF THE DISEASE 

scar tissue is delayed and made uneven and excessive 
in amount, as the formation of the ice on the pond is 
disturbed by the ripples and waves. 

Immunity. Nature also elaborates certain sub- 
stances in the cells and tissue juices of the body which 
tend to check the growth of the bacilli and to kill 
them. The nature of these substances is not yet 
clearly understood. Upon them depends the relative 
degree of immunity which is established in tuber- 
culosis. In small-pox and typhoid fever, for instance, 
the immunity established is complete, and the patient 
has these diseases only once. In pneumonia, for 
example, there is apparently no immunity established, 
or rather it is very transitory, and the patient may 
suffer from frequent attacks. 

Koch discovered the significant fact that if an 
animal were infected with tuberculosis, and later a 
second inoculation made, the focus of infection from 
the second inoculation remains localized, ulcerates, 
sloughs out and heals leaving only a scar, and does 
not spread to the underlying lymph glands and other 
tissues as the first infection always does. This 
clearly shows that the first infection produces a cer- 
tain amount of immunity which is able to prevent the 
spread of subsequent infections, but is not sufficient 
to control the original infection. 

This experiment led him to the discovery of tuber- 
culin, and the attempt to produce immunity by giving 
tuberculin treatment, but such attempts have yielded 
small results so far. 

23 



TUBERCULOSIS 

Tendency to Relapse. Tuberculosis is a disease 
which tends to relapse. This occurs when some over- 
strain or infection, etc., is able to fan the old foci into 
renewed activity, or when through lowered resistance 
the bacilli are enabled to invade new areas. Hence 
a person who has been "cured" should not consider 
himself as entirely free from living bacilli. This 
should be no cause for worry, but rather looked upon 
as a "safety first" reminder, for it is not incompatible 
with the enjoyment of health and activities. 

Infants, Children, Adults. In infancy the most 
common form of tuberculosis is generalized miliary 
tuberculosis and tuberculous meningitis, and is 
practically always fatal. In children tuberculosis of 
the glands, bones and joints is the common form, and 
chances of recovery are excellent if proper care and 
treatment is carried out. In adults pulmonary tuber- 
culosis is by far the most common form. It has a 
pronounced tendency to become chronic, is certainly 
amenable to treatment, and the earlier the treatment 
is begun the better are the chances of recovery. 



24 



'*^. IV -<fcr* 

DANGER SIGNALS 

"Let thine ear now be attentive, and 
thine eyes open" 

"The prudent man foreseeth the evil 
and hideth himself; but the simple pass on 
and are punished." 

Wisdom and Folly. Tuberculosis, in a large 
majority of cases, comes on gradually and insidiously, 
and there are signals, as a rule, months ahead of the 
"breakdown" to warn us if we have our ears attentive 
and eyes open, as the writer exhorts us in the quota- 
tion above. It is upon these warning signals that I 
wish to dwell for a few pages now, and to emphasize 
the wisdom of heeding them, and to point out the 
folly, loss of time and money, and disastrous results 
that may ensue if we refuse to give ear to them, and 
seek and follow the advice of a physician competent 
to direct in these matters. 

It is of the greatest importance to realize that if 
tuberculosis is taken in hand at the time of these early 
warnings a serious "breakdown" can be prevented, 
and a complete arrestment of the disease obtained in 
a few months of proper treatment in as high as 80 or 

25 



TUBERCULOSIS 

% of cases, while if one waits until the break 
comes the period of treatment is three to ten times as 
long and the results obtained much less satisfactory. 
And yet there are many who, when aware of these 
early symptoms, say that they just can't afford to stop 
and take a few months off, when the most elementary 
considerations of finance and prudence should con- 
vince them that they can ill afford not to do so. The 
law of chances on the one hand that they will not 
break down is strongly against them, and on the other 
hand the chances of averting the breakdown and re- 
placing their health on a stable foundation is over- 
whelmingly in their favor. If we could get such 
favorable odds in any financial adventure there would 
be a headlong rush for them, but when "health" is 
the stake we develop indefensible and simple-minded 
nearsightedness and stumble along at a snail's pace 
toward the goal. 

It is not my desire to disturb the mental equi- 
librium of nervous types of individuals by reciting 
the early symptoms of tuberculosis, but if I can 
scare some into having an early diagnosis made, and 
treatment begun, it will far outweigh any groundless 
fears that may be aroused. 

Early Symptoms Obscure. The earliest symtoms 
of tuberculosis are by no means always easy to recog- 
nize and identify. The patient may not be aware 
that anything is wrong more than a vague feeling that 
things are different from what they used to be. If 
they are asked the question, "How long has it been 

26 



DANGER SIGNALS 

since you felt perfectly well?" they will often be sur- 
prised to discover that it has really been months, or 
even years. 

To enumerate more specifically we may mention 
the following symptoms which should arouse 
suspicion: 

(1) Change of mental attitude — more irritable 
disposition — tendency to be upset and worried by 
small things which formerly would not disturb your 
equilibrium. 

(2) Lack of endurance with slow recovery from 
fatigue. 

(3) "Don't care" attitude — tasks that were for- 
merly easy and pleasant become difficult and unin- 
teresting. 

(4) Capricious appetite, with unexplainable loss 
of weight of five or ten pounds. 

(5) Unstable pulse of 85 or more in men, and 
90 or over in women. 

(6) Frequent colds which "hang on" and slow 
recovery from other diseases. Symptoms of tuber- 
culosis are apt to appear for first time during such 
periods. 

(7) Cough which persists for a month or more. 

(8) Temperature of 99.4 or over on several suc- 
cessive days. 

(9) Spitting of blood which does not definitely 
come from nose or mouth nearly always indicates 
tuberculosis. 

27 



TUBERCULOSIS 

(10) Pleurisy which is not definitely associated 
with pneumonia or an injury is practically always 
tuberculous. 

(11) Fistulae are very often of tuberculous 
origin. 

(12) Unexplainable hoarseness. 

(13) Enlarged glands, especially in children. 

(14) Exposure to infection, especially in child- 
hood. 

(15) Night sweats. 

Many of these symptoms, of course, appear in 
other infections and diseases, but if a definite and 
undoubted diagnosis cannot be made, tuberculosis 
should be suspected and carefully looked for. 

Classification of Symptoms. Dr. Pottenger* has 
very conveniently arranged the symptoms of tuber- 
culosis in three groups as follows : 

( 1 ) Symptoms due to toxemia 

Run-down feeling 

Lack of endurance 

Loss of strength 

Nervous instability 

Digestive disturbances 

Loss of weight 

Increased pulse rate 

Night sweats 

Fever 

Blood changes 



♦Pottenger (F. M.), Clinical Tuberculosis, C. V. Mosby 
Co, 1917. 

28 



DANGER SIGNALS 

(2) Reflex origin 

Cough 

Pains in chest and shoulder 
Digestive disturbances 
Circulatory disturbances 
Flushing of face 

(3 ) Tuberculous process per se 

Frequent and protracted colds 

Pleurisy 

Haemoptysis 

Sputum 

Hoarseness 

Fever 
Feelings Deceptive. The toxic symptoms are 
usually the first to appear, and also to disappear. It 
is this group of symptoms which makes the patient 
realize that he is sick. It is important to know that 
active tuberculosis may be present without mani- 
festing toxic symptoms, at least symtoms that the 
patient will recognize; and also to realize that the 
patient is not well as soon as these toxic symptoms 
disappear, although he may feel perfectly well. It 
takes much longer for the other two groups of 
symptoms to disappear, and for healing to take place 
in the lungs. —* ^ 

Forms of Tuberculosis and Mistakes in Diagnosis. 
Tuberculosis assumes various forms and may often 
be mistaken for other diseases, especially in the early 
stages. (1) Catarrhal form — this is probably the 
most frequent source of mistaken diagnoses — often 

29 



TUBERCULOSIS 

diagnosed as colds, bronchitis, colds in the chest, 
etc. (2) Febrile, or malarial form — often diagnosed, 
especially in malarial distrists, as malaria. (3) 
Dyspeptic form — may be called indigestion, etc. (4) 
Pleuritic form — importance of pleurisy is often mini- 
mized; patients are told they will be all right in a 
week or two, or that they are threatened with tuber- 
culosis, when in fact they have it. About 90% of 
all cases of pleurisy are tuberculous, when not asso- 
ciated with pneumonia. (5) Anaemic form — may 
be diagnosed as anaemia, or as chlorosis in girls and 
women. (6) Nervous form — often called neuras- 
thenia. (7) Laryngeal form — may be passed over as 
sore throat, or simple laryngitis. (8) Haemoptotic 
form — as in the case of pleurisy the patient may be 
told that a little spitting of blood does not amount 
to anything, that they are all right, when in fact it is 
the herald of tuberculosis. (9) Traumatic form — 
tuberculosis sometimes develops at the site of an 
injury. 

It is impossible to over-emphasize the importance 
of early diagnosis and treatment in tuberculosis. If 
your family physician is in doubt about the diagnosis 
don't hesitate to consult a specialist. 



30 



*^. V '^c9i 

GOOD AND BAD ADVICE 

"When a man's knowledge is not in 
order the more of it he has the greater will 
be his confusion" 

Pleasant vs. Good Advice. All shades and 
qaulities of advice can be had for the asking — and 
often without the asking. Ignorance of the issues at 
stake does not restrain these voluble advisers from 
proffering their well-meant but misdirecting and 
meddlesome advice with great assurance and in- 
sistence. Ne'er-do-wells and failures in all walks of 
life are notorious advisers. One danger from such 
advice is the tendency to accept it when it coincides 
with our whims and pleasure in preference to the best 
advice, which may not be so convenient and pleasant 
to take. 

Groundless Advice. The habit of laymen, espe- 
cially "ex-t. bs.," of giving advice to tuberculous 
patients when they are absolutely ignorant of the 
pathology and physiology of the disease, and espe- 
cially of the patient's physical condition, is a per- 
nicious one. Truly, in this province, "fools rush in 
where angels fear to tread." Such advice is nearly 
always based on the fact that they know Mr. A. who 

31 



TUBERCULOSIS 

did so and so, or went to a certain place, and either 
got well or didn't get well. When we consider the 
fact that many patients get well in spite of numerous 
follies and dangerous practices, and on the other hand 
that many die under the very best treatment and con- 
ditions, it should be evident that the few cases which 
come within the ken of the laymen should really have 
no influence in the matter. 

Physicians and Advice. All physicians, unfortu- 
nately, are not qualified to give good advice — cer- 
tainly not the best advice — in tuberculosis. Dr. 
Pottenger says, "The general apathy of the pro- 
fession toward tuberculosis, and neglect to study it as 
its seriousness and frequency deserve, lead to a lack 
of confidence in their ability to diagnose and treat it 
satisfactorily." And some make this situation worse 
by neglecting to send doubtful cases to a physician 
who has made a careful study of the disease and 
understands it thoroughly. It is a deplorable and 
inexcusable practice to lull the patient into a false 
security by telling him that there is nothing the 
matter, that he is just in a run-down condition, or 
has weak lungs, etc., while waiting for absolutely 
unmistakable physical signs, and bacilli to appear in 
the sputum. Such a course reduces the patient's 
chances from 80 or 90% to 50 or 60%. Dr. Eisner* 
has stated the situation as follows: "To wait for 
definite physical signs (in tuberculosis) before mak- 



*Monographic Medicine, D. Appleton & Co., 1916, Vol. 
VI. 

32 



GOOD AND BAD ADVICE 

ing a diagnosis darkens prognosis, for the patient's 
chances are reduced thereby. To anticipate the final 
development in cases which are strongly suggestive 
adds to the patient's chances. Positive physical 
signs are never early evidence of lung infection ; they 
mean that the case is advanced." Cheap advice 
which leads to delayed diagnosis and mistakes in 
treatment proves in the end to be very dear. 

Sanatorium or Home Treatment? One of the 
first and most important questions to be decided is 
whether the patient should be treated in a sana- 
torium or at home. Rules cannot be laid down for 
all cases. It must be decided separately for each 
case, and the advice of an expert should be sought in 
the matter. In general it may be said that, if other 
things are equal, the sanatorium offers twenty to thirty 
per cent better chances than the home, and possibly 
even higher percentages in some cases. Advice in this 
matter depends on: (1) stage and duration of the 
disease, (2) financial condition, (3) temperament, 
habits, social condition, family ties of patient, (4) 
age. 

It is manifestly unwise to send a hopeless case to 
a distant sanatorium, and yet this is by no means an 
infrequent occurrence. Infants are best treated at 
home. Children do best in special institutions where 
there are arrangements for amusement, suitable in- 
struction, and careful supervision. People over sixty 
do not adjust themselves to sanatorium regime with- 
out considerable friction and often needless irritation. 

33 



TUBERCULOSIS 

Finances and temperament are important considera- 
tions. It is unwise to send an unwilling patient away 
from home to worry over his finances and worry over 
the separation from his family. 

On the other hand, the freedom from home cares 
and interruptions, and temptations of friends, and 
tendency to stop the regime of treatment too soon at 
home, and especially the educative features and daily 
visits and encouragement of the physicians are dis- 
tinct advantages of the sanatorium. The "atmos- 
phere" is congenial and sympathetic and the patient 
is not made to feel uncomfortable by well "friends" 
who are a bit timid and over-cautious about their 
own safety, or thoughtless and selfish in their atti- 
tude toward him. Everybody is doing the same thing, 
and this makes it easier for him to do it. New 
friends and faces, constant changes, and the daily 
routine make the time pass rapidly. He sees the 
mistakes and follies of some that cause relapses and 
prolong the cure, and he has the association and 
example of others who are improving and leaving as 
"cures" to stimulate him to put up his best fight. 

Specific Directions. Specific directions as to rest 
and exercise, diet, symptomatic treatment, etc., must 
come from the doctor in charge of the case, and they 
will vary according to the stage and progress of the 
disease. No course of treatment can be outlined for 
three or four months in advance, and the patient sent 
off into the wilderness with a camping outfit to regain 
his health. The patient should have constant medical 

34 



GOOD AND BAD ADVICE 

supervision and encouragement, and the symptomatic 
treatment must be changed from time to time to meet 
whatever demands may arise. 

The defeatist attitude, or laissez faire policy, of 
some physicians and patients is pernicious and will 
reduce one's chances to about half of those offered 
by a vigorous and persistent plan of treatment insti- 
tuted at the earliest possible moment. 

Arrestment of Disease and Change of Occupation. 
It is important to realize that no patient can be con- 
sidered "cured" in less than two years after the dis- 
appearance of symptoms. The question of occupa- 
tion then arises. Can he safely return to his old one, 
or should he take up some outdoor work ? As a rule 
it is much better to return to the old one, unless it is 
a peculiarly unhealthful or laborious one. It is a 
mistake to change from easy congenial work to some- 
thing out of doors for which the patient has no apti- 
tude, and which usually involves a decrease of income 
and increase of worry and dissatisfaction. His occu- 
pation will take one-third, or less, of his time. His 
outcome will depend more on the judicious use of the 
other two-thirds, or more, of his time as regards rest, 
amusements, meals, etc. On this subject Dr. David 
A. Stewart, of the Manitoba Sanatorium, has laid 
down the following general principles: 

(1) Work for those with arrested disease must 
not be physically heavy. 

(2) Possibly the most deeply rooted wrong idea 
concerning work for tuberculous persons is that out- 
door occupations are essential. 

35 



TUBERCULOSIS 

(3) It is particularly desirable that a tuber- 
culous person should earn a good wage so as to make 
good living conditions possible. 

(4) A tuberculous patient needs a permanent 
occupation. 

(5) If at all possible, it is better for a man to 
return to his old occupation, or some modification 
of it. 

(6) A suitable job for a tuberculous patient 
should be one which makes it possible for him to live 
at his own home. 

General Advice. (1) Be hopeful and cheerful, 
for your disease is curable. Avoid worry and 
anxieties which prolong, and may prevent the cure. 

(2) Do not tell all your troubles and fears to the 
other patients and people, and dwell on and magnify 
them in your own mind. They have troubles enough 
of their own, and such thoughts and conversations 
are depressing. The doctor is the proper one to hear 
such complaints, and to advise accordingly. 

(3) Stay in the open air and sunshine as much 
as possible. Protect your head from the direct rays 
of the sun and never remain in the sun until you feel 
weak, faint, or enervated; and do not allow the sun 
to run up your temperature by staying in it too long 
at a time. In cold weather wrap up carefully and do 
not allow yourself to become chilled while sitting or 
sleeping out. 

(4) Never sleep or stay in a hot, close room, and 
do not shut out the night air — it is generally purer 

36 



GOOD AND BAD ADVICE 

than the day air. Maintain the best ventilation pos- 
sible both day and night, and let in all the light 
possible. 

(5) Protect yourself from cold damp winds and 
draughts, but do not close up your room in order to 
accomplish this — use wind shields or screens. 

(6) Dress comfortably, and avoid any excess of 
heavy clothing. It is advisable to wear linen-mesh 
underwear next to the skin in order to insure good 
ventilation. It is much better to put on warm outer 
garments than under garments. Keep your feet dry 
and warm. 

(7) Harden yourself gradually to outdoor con- 
ditions and you will be in much better shape to resist 
colds and other intercurrent infections. 

(8) Do not eat when you are tired and worried, 
and do not hurry through the meal. Rest for half an 
hour before and after the principal meals, and this 
will aid both the digestive and mental processes. 

(9) Never allow yourself to become tired. Al- 
ways stop and rest at the first symptoms of fatigue, 
either mental or physical. Avoid hurry and strain 
of any kind. 

(10) Sleep nine hours or ten every night, or at 
least lie in bed that long. If you cannot sleep all this 
time do not worry about it, but lie in a perfectly 
relaxed condition, physically and mentally, and you 
will get all the rest that you require. Such a re- 
laxed condition is also a much better soporific than 
any drugs. 

37 



TUBERCULOSIS 

(11) Do not take any medicine (patent or other) 
unless prescribed by your doctor; and discontinue 
any medicine that interferes with your appetite and 
digestion. 

(12) Control your cough as much as possible. 
Unnecessary and violent coughing is harmful. A 
determined will-power and persistent effort can ac- 
complish much toward this end. I can testify that 
the will-power, stimulated by pleurisy, is a most 
effective remedy for controlling a cough. It makes 
no difference how strong the desire may be, if the 
pleurisy is severe enough the cough will be reduced 
to a mere aspirating grunt. Exercise your will-power 
independently of pleurisy! 



38 



5#^. VI '<&*> 

MORALE 

"Moral condition as regards discipline, 

confidence, indecision, courage " 

— Dictionary. 

"He that ruleth himself is greater than 
he that taketh a city." 

— Solomon. 

Morale is one of those things, like electricity, 
which is frequently mentioned, but not fully com- 
prehended. When it is low things go wrong, nobody 
seems to take any interest or care about you, you are 
worried by trivial things, listless, diverted from your 
objective — you have a "rotten day." When it is high 
you get on well with everybody, speak an encouraging 
word or do a kindness to someone, note some progress, 
on the whole there is a feeling of satisfaction with 
your efforts and a determination to do better to- 
morrow — a "good day." It is a storage battery of 
nerve force, a surplus of confidence and purpose on 
deposit, a reserve fund of discipline and courage 
which make your supply exceed the demands of the 
day. It imparts decision to action, firmness of will, 
radiates vitality — it is the mainspring of success. 

39 



TUBERCULOSIS 

Important Factor. It is just as important a 
factor for the patient as it is for the soldier. We 
have seen what a tragic spectacle Russia has pre- 
sented by allowing the morale of her army and of her 
people to be completely undermined. And we read 
in the dispatches from Austria that the morale of the 
people was so low that the Government feared 
Bolshevism; and again that the German Military 
Staff had undertaken some costly feat in order to keep 
up the morale of the people. As soon as the Germans 
believed that they were not going to win they went to 
pieces. Calculations based on a military point of 
view prophesied victory late in 1919 or in 1920, but 
they failed to consider the effects of morale. In de- 
feat the Allied morale was stubborn and inflexible, 
but when the Germans faced defeat their morale 
crumbled, and the end came quickly. When a doctor 
sees the morale of his patient ebbing away, and dis- 
contentment, worry, peevishness, and fear gaining 
ground he should be just as solicitous over his 
patient as the Allies were over Russia, for the patient 
stands just about as much chance against the invad- 
ing bacilli as the Bolshevik army did against the 
invading Germans. 

Evil Effects of Worry. It is of the greatest im- 
portance that the patient be aware of the evil effects 
of worry, peevishness, and a fault-finding habit. He 
is not playing the game fairly under such conditions, 
and does not put himself in position to receive the 
best results from any form of treatment. A spirit of 

40 



MORALE 

healthy-mindedness, optimism, and courage is a great 
asset, and one that should be assiduously cultivated. 
Health of body and mind act and react on each 
other — "a merry heart doeth good like a medicine." 

Serenity. Serenity sums up the qualities of mind 
that the patient should aim at, and it is an art that 
can be attained and improved by practice. The secret 
of serenity is the ability to control our attention. One 
can attain the ability to turn off the current of his 
thoughts as he would turn off the electric light. And 
when his thoughts turn toward despondency, grief or 
morbid fears he should turn off this current, and turn 
on a current of cheerfulness, courage, patience, and 
optimism. The little Sunday-school song "Count 
your blessings, name them one by one" is a good way 
to accomplish this. 

Religion and Philosophy. Wm. James, the great 
psychologist, has said that we should cultivate and 
practice a religion of healthy-mindedness, courage, 
patience, optimism, and reverence. We should cer- 
tainly have some religion and philosophy which will 
serve as light-houses to keep us out of the Slough of 
Despond. The philosophy of the Bible, of Marcus 
Aurelius, of Emerson is an excellent tonic of mental 
hygiene. 

One Day at a Time. There is a tendency for 
many patients to cross their bridges before they get to 
them — to suffer many things in their minds that they 
are never called upon to endure. This is not only 
useless and foolish worry, but it exerts a bad influence 

41 



TUBERCULOSIS 

on the course of the disease by its depressing action 
on the physiological functions of the body. A good 
way to avoid such unnecessary worry is to live one 
day at a time, or if necessary one hour at a time. We 
can gradually gain self-control and confidence in 
this way, remembering the adage "the more haste, the 
less speed." We should learn to pass our crises un- 
ruffled, no matter what happens, and then we shall be 
much more apt to pass them successfully. 

Physiological Effects of Emotions. The effect of 
emotions on the nervous mechanism of the body is 
well known. Shame or embarrassment causes a 
dilatation of the blood-vessels of the face with a rush 
of blood into the dilated vessels, and the result is 
known as blushing. Fear produces the opposite 
effect, a constriction of these blood-vessels, with a re- 
sulting pallor of the face. A shock may produce 
fainting by causing a dilatation of the abdominal 
vessels with a rush of blood away from the brain into 
these dilated vessels, and the resulting anaemia of 
the brain is responsible for the fainting. Grief or 
joy may cause a flow of tears which come from little 
glands situated just above the eyes, and are due to 
the nervous stimulation by these emotions. Sudden 
news, good or bad, may cause a complete loss of 
appetite temporarily. Worry has a very marked 
effect on digestion by exerting a depressing effect on 
the glands that supply the digestive juices to the 
stomach and intestines. Most interesting and in- 
structive experiments have been done on animals in 

42 



MORALE 

which it has been observed that such emotions as fear 
and anger may cause a cessation of the peristaltic 
movements of the intestines, which are very necessary 
for the proper digestion of food and functioning of 
the intestines. 

Cause of Depressive Emotions. Robert Burton, 
in his Anatomy of Melancholy written in 1661, gives 
an amusing account of the search for the cause or 
seat of melancholy, or depressive emotions. Various 
insects and small animals with supposedly morose 
dispositions were dissected in the effort to locate the 
cause of these emotions. Now we are aware of the 
fact that the toxines and poisons produced by various 
infections and diseases may produce these depressive 
emotions by their action on the nerve centres. It is 
therefore all the more necessary for the tuberculous 
patient to exert a greater effort to be cheerful and 
agreeable to those about him, and to strengthen his 
will-power (by using it) in order that he may over- 
come this added tendency to depressive emotions and 
peevishness which comes from the toxines of his 
disease. A cheerful, optimistic, courageous disposi- 
tion will more than offset the effect of the toxines on 
his physiological functions in most cases. 

Toxic Effects Increased by Depressive Emotions. 
One effect of toxines is to produce an inhibition of 
the functions of the internal organs, and this effect is 
increased and prolonged by such depressive states as 
pain, anxiety, fear, disappointment, discouragement, 
and general nervous depression. We repeat again 

43 



TUBERCULOSIS 

that hope, cheerfulness, contentment, and a whole- 
hearted co-operation on the part of the patient are 
very important factors in the prognosis of any case. 

Self-Control. Dr. Lawrason Brown sums up the 
situation as follows: "After all, the most important 
thing is to be able to control one's self. If a man does 
not develop self-control while he is 'curing' so that 
when he is asked to do things he knows he should 
not, and to which he cannot say no, then this time has 
been lost. Unless a patient can say no when the 
occasion arises, his chances for getting well are very 
slight. He can tear down in one day or in an hour 
what it has taken him months to build up." 

"He that ruleth himself is greater than he that 
taketh a city," and incidentally he is in much better 
shape to "take the city." 

"Look up and not down, look forward and not 
backward, 
Look out and not in, and lend a hand!" 



44 



WH VII ^#b 
PREVENTION AND CURE 

"It may well be claimed that the care of 
individual and family health is the first 
and most patriotic duty of a citizen." 

— Taft. 

"To successfully combat consumption as 
a disease of the masses requires the com- 
bined action of a wise government, well- 
trained physicians, and an intelligent 
people." 

— Knopf. 

Is it possible to relegate tuberculosis to the back- 
ground as small -pox and yellow fever have been? 
Tuberculosis, the greatest scourge in all history! 
When everyone is thoroughly awake to the situation 
that it can be much more easily and cheaply pre- 
vented than cured, and translates present knowledge 
of the subject into action, a big advance toward this 
end will be made. The results of preventive measures 
are incomparably better than the patch work and 
repair of manifest disease. Hospitals and almshouses 
are much more expensive institutions to support than 
would be the necessary measures and personnel to 

45 



TUBERCULOSIS 

enforce effective prevntion. And how much better it 
is for the individual to be able to support himself 
than to be an object of charity ! 

When the tubercle bacillus was discovered in 
1882 many prophesied that it would be a back num- 
ber in one generation. This phophesy has not been 
fulfilled, neither have the very simple conditions laid 
down for the eradication of tuberculosis been car- 
ried out. And so the possibility still remains though 
somewhat disfigured by inadequate effort and doubts, 
and still lacking the education, means, and legislation 
necessary to give it a fair trial. 

Pasteur, the great French scientist, said: "It is 
within the power of man to rid himself of all parasitic 
diseases." The wonderful results that have been ob- 
tained from preventive measures in such diseases as 
small-pox, yellow fever, typhoid and dysentery in the 
army, typhus epidemics, and malaria add confirma- 
tion to his statement. The disease death rate per 
thousand per year for wars in which the United States 
has engaged in recent years shows the following re- 
markable drop due to the discovery and enforcement 
of preventive measures in the army. Mexican War, 
110 per 1000; Civil War (North), 65 per 1000: 
Spanish War, 26 per 1000; Last War, 17 per 1000. 
Such achievements surely add color to the reality of 
this possibility, and should stimulate efforts to give 
it a thoroughly fair trial. 

The prevention of tuberculosis essentially falls 
under two heads: (A) prevent infection from taking 

46 



PREVENTION AND CURE 

place; (B) after infection has occurred prevent it 
from becoming clinical tuberculosis. In view of the 
fact that under present conditions 75 to 100% of 
adults are infected the latter consideration becomes 
the more immediate and practical, while the former 
remains the ideal. 

(.4) Prevent Infection. It is reasonable to sup- 
pose that this could be accomplished almost in one 
generation if every tuberculous individual would ob- 
serve carefully the simple precautions: 

(1) Never expectorate anywhere or in anything 
except waterproof cups that can be burned. 

(2) Never cough or sneeze without holding a 
paper or gauze square over the mouth and nose, use 
the square only once, and then place it in a paper 
bag and burn them. 

(3) Wash their mouths, faces, and hands fre- 
quently, and take care not to infect the food and 
dishes that their children and associates use. 

This would account for about 90% of tuber- 
culosis. The other 10% comes from cows, and the 
obvious remedy is to slaughter all tuberculous cows, 
and pasteurize all milk that does not come from tuber- 
culin tested herds. 

A House Disease. It is well recognized now that 
tuberculosis is essentially a house disease, and is 
probably never contracted in the open. Direct sun- 
light is the best disinfectant that we have, and also 
the cheapest, therefore we should make the greatest 
possible use of it. Dark, damp, dirty, and poorly 

47 



TUBERCULOSIS 

ventilated rooms and houses should not be tolerated. 
Tubercle bacilli can live in such rooms and remain 
virulent for many months, whereas in strong direct 
sunlight they are killed in a short time, and in 
diffused or reflected light they die more slowly, de- 
pending on the degree of light. We go to Sunday 
school and sing "Let the blessed sunshine in" and 
then come home and shut it out, and further vitiate 
the atmosphere in our houses by cutting off all venti- 
lation, and then turn on too much heat. 

Light, Ventilation and Heat. The maximum 
amount of light, good ventilation, and not too much 
heat are not only excellent precautions against tuber- 
culosis, but also against headaches, languor, colds, 
and all other infectious diseases. 

Careless spitting and coughing furnish the 
material for the spread of infection; and poverty, 
unsanitary surroundings, crowding, dissipation, and 
overwork are the bellows that fan infection into active 
disease. Infants and children who are exposed to 
such conditions have no chance of escaping infection ; 
and adults who live under and tolerate them, espe- 
cially during the period of life (18 to 30 years of 
age) when clinical tuberculosis most frequently 
develops, greatly increase the danger of their old foci 
of infection breaking out into manifest disease. 

Information, Perseverance and Legislation 
Needed. We know the cause of the disease, namely, 
the parasitic tubercle bacillus which cannot live very 
long outside of it's animal hosts; and we know the 



PREVENTION AND CURE 

sources of infection, namely, careless spitting and 
coughing, and infected cows and food. Some of us 
need only information on the above points; some lack 
the initiative and perseverance necessary to carry 
them out; and some need the restraining influence 
and forceful help of legislation, and even isolation. 

The very simplicity of these measures confounds 
us, and we go on tolerating ignorance, carelessness, 
and viciousness, and look for a specific cure, when, 
even if we had the cure, the preventive measures 
which we now neglect would still be important and 
necessary. 

(B) Prevent Infection from Becoming Manifest 
Disease. This is the immediate and practical 
problem that confronts us. The Journal of the Out- 
door Life has laid down the five fundamental prin- 
ciples on which the control of tuberculosis must be 
based, namely: 

(1) The discovery of the case and reporting of 
same to the health authorities. 

(2) The facilities for the care and instruction of 
curable cases shall be adequate and shall be properly 
equipped and maintained. 

(3) The segregation of the infectious and com- 
municable case. On this point there is not unanimity 
of opinion, but all agree that isolation of the careless, 
dangerous case is a necessary health measure. 

(4) The education and treatment of the non- 
infectious case by dispensaries, visiting nurses, etc. 

(5) Education of general public, first, in regard 

49 



TUBERCULOSIS 

to nature and prevention of tuberculosis, and, second, 
how to maintain a strong resistance to disease. 

More specific measures include: (a) Preventoria 
for babies of poor, or careless, families in which they 
are exposed to massive infection and frequent rein- 
fections which play an important part in the develop- 
ment of the disease. In these institutions, and in 
private families that adopt these children for a few 
years as they do under the Grancher Society in 
France, these children are safeguarded against ex- 
posure to infection. (b) Fresh air schools and 
colonies for children that show evidence of tuber- 
culous disease. Here, these children are assured of 
proper treatment and nourishment, and the amount 
of study and work that is safe for their physical 
conditions. 

For adults a sane amount of restraint must be 
applied to their mode of living and activities, espe- 
cially during the period of 18 to 30 years of age when 
the great majority of breakdowns occur. Dissipation, 
irregular hours, variable time, quantity, and quality 
of meals, overwork, high tension, and worry must be 
replaced by self-control, regular habits, sanitary liv- 
ing and working quarters, periodic health examina- 
tions, serenity, and healthful outdoor recreation if the 
more susceptible individuals are to pass this period 
safely. 

Summary. We have stated that the dangerous 
period for acquiring tuberculous infection is in in- 
fancy and childhood, and that early clinical tuber- 

50 



PREVENTION AND CURE 

culosis in adults usually comes from old foci of in- 
fection contracted in childhood. Therefore we should 
concentrate attention on: 

(A) Prevent infection from taking place by pro- 
tecting children from careless consumptives and sus- 
picious cases who may be inclined to kiss and fondle 
them; keep them out of contaminated rooms, and by 
no means allow them to play and crawl around on 
such floors, and put various objects in their mouths; 
do not let them take infected food and milk, or eat 
from dishes used by consumptives unless they have 
been thoroughly scalded. Under no conditions should 
a baby be nursed by a tuberculous mother, or attended 
by a tuberculous nurse. 

(B) When infection has occurred give careful 
attention to the thorough cure and healing of the foci 
— remembering that this will take a year or two, and 
must be followed by careful living, proper food, life 
in open as much as possible — in short, maintain a 
high degree of resistance. 

Enumeration of Preventive Measures. ( 1 ) Burn 
all sputum — most important — and all articles that 
come in contact with the mouth, such as toothpicks, 
fruit cores, cigar butts, etc. 

(2) Always cover mouth and nose with paper or 
gauze when you cough or sneeze, and burn the squares 
— most important ! This practice should also be ob- 
served in colds and other respiratory infections. 

(3) Do not use infected food — at least in the 
raw state. If there is any question about the milk 

51 



TUBERCULOSIS 

supply it should be boiled, or pasteurized, especially 
for children. If possible, it is much safer to use 
milk from tuberculin tested cows. 

(4) Protect children from careless consumptives 
and contaminated rooms. 

(5) Let in maximum amount of light, and al- 
ways have good ventilation, and not too much heat — 
not over 68 degrees. 

(6) Sun clothing and bedding of patient fre- 
quently; boil nightclothes and bedding when they 
are washed. 

(7) Patient should wash his mouth, face, and 
hands frequently, and use soap freely. 

(8) Always use moist broom and cloth for sweep- 
ing and dusting in patient's room. 

(9) Live hygienically; give attention to proper 
amount and cooking of food ; avoid late hours, dissi- 
pation, and over-strain; employ leisure time in 
healthful outdoor amusement; keep "fit." 

(10) Periodic examination for those in any way 
exposed to infection, and for under-nourished, weakly 
children. 

(11) Early diagnosis and adequate treatment — 
never neglect a cold that hangs on, for it may be the 
beginning of tuberculosis. 

(12) When a patient vacates a room have it thor- 
oughly cleaned as follows: first, fumigate with 
formaldehyde gas; then wipe down ceiling, walls, 
and floor with some antiseptic solution such as cresol, 
or liquor cresolis compositus; and finally give walls 

52 



PREVENTION AND CURE 

and floor a thorough scrubbing with hot carbolized 
soap-suds (two tablespoonfuls carbolic acid to quart 
of water) , then open up room to maximum amount of 
light and air for two days. It will be perfectly safe 
after such treatment. If you move to another house 
take care to find out if there have been any tuber- 
culous inhabitants in it, and if so, whether it has been 
disinfected as above. Repapering, painting, varnish- 
ing, or calcimining the walls and ceiling are safe 
methods, but more expensive than the above measures. 

Remarkable Progress. Hippocrates wrote more 
than twenty-two hundred years ago, "The disease 
which proved most dangerous and produced the 
greatest number of deaths was consumption." And 
this statement held true until a year or so ago. A 
few years ago Pry or said, "We must care for the 
consumptive in the right place, in the right way, and 
at the right time until he is cured; instead of, as 
now, in the wrong place, at the wrong time, in the 
wrong way until he is dead." These statements can 
no longer be made with entire truth and justice. No 
disease has responded more favorably to the meagre 
sanitary and preventive measures that have been par- 
tially and half-heartedly adopted than has tuber- 
culosis. 

United States. The death rate from tuberculosis 
in the United States in 1890 was 254.4 per 100,000 
population; in 1900 196.9; in 1910 it was 160.3— 
a drop from one-seventh of all deaths in 1890 to one- 
tenth in 1910. And in 1921 the death rate was 120 

53 



TUBERCULOSIS 

per 100,000. a drop of Sl^c in 30 years, and tuber- 
culosis has dropped from first place to third place as 
a cause of death. When we consider the history of 
tuberculosis for the past twenty-five hundred years 
this is a truly remarkable achievement for thirty 
years. 

I 'titer national Statistics. In contrast to these 
figures for the United States Coni quotes, some in- 
teresting international statistics in the Journal Am. 
Med. Assoc, April 27, 1918, which shows the ap- 
palling results from tuberculosis in countries where 
little is done to prevent it. His table shows the death 
rate to be: Spain, 500 per 100.000 population; 
Greece, 40S: France. 390: Austria. 270: and Italy, 
ISO. England with 150 per 100.000 makes a better 
showing than the United States. 

England. In England the death rate from tuber- 
culosis has declined 54% since 1850, following upon 
the establishment of dispensaries for the early 
diagnosis of cases, visiting nurses, notification of 
cases, establishment of sanatoria, and isolation of 
advanced cases. 

Ireland. Ireland presents a striking contrast to 
the above situation. Owing to the ignorance and 
poverty of her population, and the failure to adopt 
and enforce such measures as the above, there has 
been an increase of 18% since 1866. 

Denmark. Denmark is in many respects a model 
which would be well for other countries to follow. 
She has many excellent sanitary laws, including the 

54 



PREVENTION AND CURE 

control of tuberculous cattle. Her health authorities 
can inspect and condemn (when desirable) dwellings, 
slaughter houses, plans of construction, equipment, 
cleaning of school buildings, milk and meat supplies, 
etc. Disinfection of the house after the death of a 
tuberculous patient, the removal of a patient from his 
house, or the removal of children from their homes 
when they are exposed by careless parents, is within 
the discretion of the Department of Health. Notifi- 
cation of cases is compulsory. Spitting in public 
places, and overcrowding in factories and workshops 
is prevented by law. Educational matter on the 
dangers of infection and the means of prevention is 
widely distributed. 

Cure. One hundred years ago Laennec, the great 
French clinician, said, "The cure of consumption may 
be possible for nature, but it is not so for medicine." 
No doubt he was impelled to say this after reflecting 
on the measures then in vogue, which included pur- 
gatives, emetics, blisters, bleeding, and the inhalation 
of various gases including the air of cow stables. 
Unfortunately many credulous souls still waste much 
time and money on medicines foisted upon the public 
by unscrupulous proprietors. 

It is unanimously agreed that the most important 
factor in the cure of tuberculosis is adequate rest. 
Next in importance comes careful supervision by a 
competent doctor. Competent, in this case, includes 
not only knowledge and experience, but a personality 
that is able to make the patient co-operate. Indeed, 

55 



TUBERCULOSIS 

this might be put ahead of No. 1, or at least as an 
essential preliminary, for adequate rest is not likely 
to be obtained without competent supervision. Diet, 
exercise, fresh air, climate, morale, tuberculin, and 
other special measures are important aids. Time is a 
factor that must not be overlooked, nor curtailed. 
Healing is a slow process and we must make provision 
for an extended and variable period of "taking the 
cure." 

There is no longer any reason for a fatalistic 
attitude toward tuberculosis. Of all serious infectious 
diseases it is the most curable when taken in a 
reasonably early stage. It requires repeated exposure 
for the infection to gain headway, and the disease 
develops slowly, as a rule, offering chances for arrest- 
ment if we would only take advantage of them early 
and persevere until a thorough arrestment is obtained. 
Advanced cases are by no means hopeless. While 
there is a tendency, after it has reached an advanced 
stage, for it to be progressive, still many arrests are 
obtained in such cases, and not infrequently in seem- 
ingly hopeless cases. The chances of cure are pro- 
portional to early treatment, and the earlier the treat- 
ment the better are the results, not only as regards the 
chances of securing an arrestment, but also as to the 
permanency of the results. 

The "cure" in tuberculosis is not as complete as 
in pneumonia, for instance. Tubercle bacilli remain 
within the scar tissue which is formed around the foci 
of infection, and it must be remembered that relapse 

56 



PREVENTION AND CURE 

is always possible, even after many years. "Cure, 
then, is possible, and to maintain it requires not an 
invalid's life always scared of a relapse, but a con- 
stant remembrance of the facts learned, and a denial 
of certain indulgences, both of pleasure and of work, 
which have been found to be unsafe for the recovered 
consumptive." (Pamphlet 106, Nat. Tub. Assoc.) 

The National Tuberculosis Association was 
formed in 1904, and among the several hundred 
present on this occasion more than one-third were 
"ex-t. b's" — robust proofs of the curability of 
tuberculosis. 



57 



**fc VIII \k9i 
CLIMATE AND ALTITUDE 

"As soon as man finds himself spitting 
and hacking on arising in the morning, he 
should immediately take possession of a 
cow and go up into the mountains and live 
on the fruit of the cow." 

— Celsus (B.C. 25-A.D. 50). 

Not Essential. It is, perhaps, well to say at the 
beginning of this chapter that climate and altitude 
are not essentials in the treatment of tuberculosis, 
but that they increase the chance of recovery is gen- 
erally accepted by the best authorities on the subject 
today. 

Belief. A belief in the beneficial effects of cli- 
mate and altitude upon tuberculosis has existed from 
the earliest times in which descriptions of the disease 
unmistakably fit tuberculosis. Erroneous beliefs and 
mistakes in practice have crept into medicine from 
time to time, but none have survived the test of 
twenty centuries or more. It would seem then that 
this belief in climate must rest on firm foundations. 

Exaggerated Importance. A few years ago cli- 
mate was given first place in the treatment of tuber- 
culosis. This idea became firmly established in the 



58 



CLIMATE AND ALTITUDE 

minds of the people. They went West, or were sent 
West, in all conditions and under all circumstances, 
and some of them regained their health — a larger 
percentage probably than would have done so had 
they remained in their old environment. But many 
did not, and it was unquestionably bad advice, and a 
fatal mistake for many of them to come in the con- 
dition and under the circumstances in which they 
came. Such indiscriminate advice, fortunately, is 
rarely given by doctors today; but one still meets 
patients in the Southwest who were advised to "go 
West and rough it." This advice is always wrong in 
tuberculosis, and means failure in many cases that 
could have been saved at home under proper manage- 
ment and treatment . 

Reaction. With the advent of sanatorium treat- 
ment and the marked improvement in the results ob- 
tained, not only in the good climates, but also in the 
bad ones, some physicians began to question the 
value of climate, and to assert that it was of no im- 
portance at all. On the other hand, some of the 
champions of climate ( a few of the pseudo-specialists 
in the Southwest with more enthusiasm than informa- 
tion), began to seize upon each physiological change 
produced by altitude and to point to it as "the 
factor" which produced the favorable results, and to 
say that "clinical experience" has proved it. As the 
value of "clinical experience" depends on the train- 
ing and intelligence of the one "experiencing it" much 
of this experience was naturally erroneous and worth- 

59 



TUBERCULOSIS 

less, and so these poor advocates of a good case did 
more harm than good for the cause. Dr. Forster has 
suggested that if Bernard Shaw had chosen this sub- 
ject for the plot of '"The Doctor's Dilemma'' he could 
have produced a much more amusing satire. 

Scientific Basis. One may ask then is this belief 
in climate and altitude purely empirical, or is there 
also a scientific basis for it? Undoubtedly this basis 
has been established. It is beyond the scope of this 
little book to enter a discussion of the relative merits 
and demerits of the changes produced by altitude 
upon the lungs, the conformation of the chest, the 
heart, the blood, and metabolism — suffice it to say 
that it is a well-established law of nature that when 
the body processes are called upon to meet an 
increased demand they respond with an over- 
production ; and it is this over-production that brings 
about the benefit in suitable cases that are able to 
react sufficiently to the stimulating influence of high 
altitude. Patients with an acute active process with 
much softening and breaking down of tissue, organic 
heart lesions, arteriosclerosis, kidney trouble, emphy- 
sema, diabetes, toxic myocarditis, and vasomotor 
weakness should not go to high altitudes. 

The important factors in high altitudes (over 
4.000 feet) are the great amount of sunshine, low 
humidity, coolness, and pure atmosphere, with a 
marked stimualting effect on the organism, and in- 
creased appetite and activity of the metabolic 
processes. Lower altitudes (under 3,000 feet) are 

60 



CLIMATE AND ALTITUDE 

warmer, less stimulating, more humid, put less strain 
on the organism, and are more sedative in effects. 
Such altitudes are suitable for the class of patients 
mentioned above who should avoid altitudes over 
2,500 to 3,000 feet. 

When a change of environment is under consider- 
ation it is very important therefore to select the 
climate and altitude best suited for each individual 
case in accordance with the condition of the lungs 
and the general condition of the patient. 

Statistics. Dr. E. S. Bullock* made a careful 
study of statistics based on three sanatoria in the 
Southwest at an altitude of approximately 6,000 feet 
and representing about three thousand patients; and 
four sanatoria in the East with the same number of 
patients. Only those patients who obtained an arrest- 
ment of the disease were considered in these statistics. 
He found that the patients treated in the Southwest 
had better chances for obtaining an arrestment of 
the disease as follows: (a) Incipient class, 9% 
better; (b) Moderately advanced, 17% better; (c) 
Far advanced, 6% better chances. 

Essentials. It is agreed that the proper manage- 
ment and supervision of a patient is vastly more im- 
portant than climate. Hence a patient should not 
leave his home in search of a better climate unless 
finances and temperament and family ties warrant 
it. Professor McSwain, formerly a professor at my 
Alma Mater, and a most intelligent and close ob- 



*Journal Am. Med. Assoc, June 19, 1909. 
61 



TUBERCULOSIS 

server, after many years of experience in various 
climates in "chasing the cure" sums up the situation 
in this incisive statement: "If a change of climate 
is to be decided upon there are more important things 
not to be overlooked. It is not fair to the big-hearted 
people of the West, it is not fair to the sick man to 
send him here without means expecting him to make 
his own living and get well. This usually means 
that he will die a burden on the charity of strangers, 
his death hastened by hardship and privation. 
Climate is something, but rest, fresh air, good food., 
and freedom from care must be added if climate is 
to do it's perfect work." 

Finances and House-Keeping Cottages. The 
minimum cost of obtaining sanatorium treatment in 
a good institution in the Southwest is about one 
hundred dollars a month. The cost of obtaining ade- 
quate medical supervision and the proper housing and 
food outside of a sanatorium would average more 
than this. Some of the sanatoria are now providing 
house-keeping cottages for their patients. This offers 
a more economical plan for a relatively large class 
of patients, as well as helping to solve the problems 
of temperament, nostalgia, and food. 

A Good Climate. The elements which make up 
a good climate and which should be considered in 
selecting a climate are: (a) sunshine, (b) tempera- 
ture, (c) humidity, (d) wind, (e) pure atmosphere. 
A maximum amount of sunshine is desirable. It 
sterilizes the atmosphere, has a favorable influence 

62 



CLIMATE AND ALTITUDE 

upon the physical feelings and mental attitude of the 
patient, and has some therapeutic value, especially in 
tuberculosis of the skin, joints, and bones. Extremes 
in temperature are undesirable. A wide variation 
(20 to 40 degrees) in the daily temperature has a 
favorable and stimulating effect. Cold dry air is a 
good tonic. Low humidity is favorable — here again 
extremes are not desirable. Damp, cold winds, and 
hot, dusty ones are to be avoided. A dry cold wind, 
if not continued long enough to "get on the nerves" 
is not harmful. An atmosphere free from dust, 
smoke, fogs, and gaseous and bacterial contamina- 
tion is desirable. Altitudes of from four to six 
thousand feet possess climates which combine more 
of these good qualities than are to be found in cli- 
mates of lower altitudes. 

The mere "change of climate," scene, and condi- 
tions, as a rule, has a favorable physiological effect 
on the patient, and the psychological effect is more 
pronounced and important. Every one is familiar 
with the effect of good weather on the mental atti- 
tude, and the difference of feeling ranging from de- 
pressing languor to exhilirating energy and optimism 
with a change from bad to good weather. Dr. King 
says in "The Battle With Tuberculosis," "Ask your- 
self the following questions: 'On which days am I 
more likely to follow the out-of-doors treatment — 
clear days or rainy days, calm days or stormy days?' 
'On which days are my spirits the more buoyant — 
sunshiny days or cloudy and wet days?' 'On which 

63 



TUBERCULOSIS 

days do I have the better appetite — when the per- 
spiration trickles down my face or when I can appre- 
ciate a light wrap?' 'On which days do I most feel 
the joy of living — when the smoke turns a somer- 
sault over the side of the chimney, or when it rises 
like a fluffy pillar straight up into the blue of 
heaven?' — more sunshine and less cloud and rain, 
more calm and less storm, greater dryness and less 
humidity, and an equable barometric pressure offer 
obvious climatic advantages." 

It is a significant fact that all of the workers in 
tuberculosis who are located in good climates are 
impressed with the value of climate. And it is fair 
to say, I am sure, that a large majority of those 
located in bad climates admit the possibility of favor- 
able influences in good climates. 

Advice on Climate. To sum up the best advice 
on climate and altitude, I would repeat that they are 
not essentials in the treatment of tuberculosis. It is 
agreed that the proper management and supervision 
of a patient is vastly more important than climate. 
However, if one can avail himself of its favorable in- 
fluence without too great a sacrifice of finances and 
too great a disturbance of his mental equilibrium con- 
sequent upon the separation from his family, friends, 
etc., and can be assured that he will be as carefully 
looked after in the new environment as in the old, it 
is certainly advisable for him to make the change. 

I agree heartily with Dr. Francine when he says, 
"Without attempting to dogmatize upon the question 

64 



CLIMATE AND ALTITUDE 

of climate, one important fact stands out, i, e., the 
sooner the general practitioner or internist ceases to 
advice change of climate promiscuously, the better it 
will be for consumptives in general and for those of 
small means in particular. Too often the physician 
out of thoughtlessness or from habit, and with self- 
complacent irresponsibility, advises a change of 
climate to those who can ill afford it, or who are not 
really proper cases from a medical point of view to 
send away. . . . Such advice cannot be too 
strongly condemned, both from a professional and 
humanitarian standpoint. But the fact remains, I 
believe, that change of climate in suitable cases 
. . . is of distinct advantage, provided always 
that the patients' financial resources are amply 
adequate." 

I quote in conclusion the late Dr. Trudeau's* 
opinion: "My experience for the past twenty-five 
years has in no way altered my opinions as to the 
beneficial influence of climate in the treatment of 
pulmonary tuberculosis. ... It is true that good 
results may be obtained without change of climate, 
but where a change of climate can be added to the 
other well-known factors which make up a favorable 
environment for the patient, better results can un- 
doubtedly be obtained, and a judicious change from 
one climate to another will often turn the tide in a 
case which has ceased to improve and carry it to a 
successful issue." 



♦Transactions 7th National Assoc. Meeting. 
65 



*^. IX M£#i 
HELPFUL SUGGESTIOMS 

" . . . forsan et haec olim meminisse 
iuvabit." 

— Vergil. 

("Sometimes, perhaps, it will be pleas- 
ing to have remembered these things.") 

Tuberculosis is a curable disease, and the largest 
part of the job lies with the patient. Close attention 
to detail and full co-operation are essential. Viola- 
tion of these principles brings its own punishment 
by retarding your improvement and seriously jeopard- 
izing your chances of recovery. A gloomy, worrying, 
fault-finding disposition is a big handicap in the 
fight. An optimistic, cheerful mood will aid greatly 
and hasten a favorable outcome. 

Some patients are prone to worry over trivial 
symptoms and things which could easily be explained 
by the doctor if he only knew of them. You should 
feel perfectly free to tell your troubles and symptoms 
to the doctor. 

Paper Bags and Napkins. Pin some paper 
napkins, cut into quarter size squares, on your bed 
to use in covering your mouth and nose when you 

66 



HELPFUL SUGGESTIONS 

cough, etc. Also pin a paper bag on the bed to 
receive these squares after they have been used, and 
also toothpicks and other things that come in contact 
with your mouth. 

Dry Heat. The most convenient and effective 
way of applying dry heat is simply to use your 
electric light. Get a tin shade long enough to come 
below the tip of the light bulb and put it on the light, 
and then place it over the spot you wish to treat. 
Put a layer of blanket around the shade in order to 
hold in the heat, and turn on the light.. You will 
have constant heat as hot as you can stand it simply 
by turning on and off the light. I found this the 
most effective way to relieve pleurisy, excepting 
codeine or morphine, which one does not want to use 
on all occasions. It is much more agreeable than a 
mustard plaster and leaves no blister behind. It is 
a thousand times more efficient than antiphlogistine, 
much easier to apply, and more agreeable for the 
patient, and costs about one-thousandth as much. 
(Note — The Am. Med. Assoc, after examining anti- 
phlogistine reported that it was entirely inert.) 

Appetite. Contrary to common belief a raw egg 
can often be taken without causing nausea when even 
the sight or smell of a cooked one produces it. I am 
not an advocate of raw eggs, except in the above cir- 
cumstances, as it has been shown that cooked eggs are 
twenty to thirty per cent more digestible than raw 
ones. 



67 



TUBERCULOSIS 

A little cold egg-bread, or cracker, crumbled in 
your sweet milk may enable you to take it when it 
seems impossible to take the plain milk. 

I found ovaltine (for sale at most drug stores), 
a powdered form of malted barley, milk and eggs, a 
palatable and nourishing drink when most other 
things seemed impossible. 

Cough. Much unnecessary coughing is done by 
patients who do not realize that it is strenuous exer- 
cise and may cause much harm. A certain amount 
of coughing is unavoidable in patients who raise much 
sputum, but it is surprising how much control over 
your cough a determined wall-power can have. For 
instance, in pleurisy one's cough is reduced to a mere 
aspirating grunt, if the pain is severe. 

It is very desirable to control your cough without 
drugs, for any drug that is efficient will upset your 
appetite and digestion when taken regularly every 
day. Hot water, or most any hot drink, sipped along 
as necessary, is the best and simplest remedy. It may 
be necessary to stop talking and laughing, or to lie 
down, or even go to bed for a few days in order to 
subdue a persistent cough. If these measures fail 
consult your doctor about drugs. (Luden's menthol 
cough drops are good and cheap.) 

If you are troubled after eating by coughing until 
you vomit your meal, or part of it, the following wili 
help you: Before meals drink cup of hot water, 
change your position and try to clear your bronchi 
and cavities of all sputum which may have accumu- 



HELPFUL SUGGESTIONS 

lated there. Take little liquid with your meal and 
rest in reclining position one-half to an hour after 
the meal. It is very important to retain what you eat. 

If you are troubled with severe coughing spells 
on sitting up in bed in the morning you can secure 
much relief by getting up by degrees. First, drink a 
cup of hot water, then raise up to about thirty degrees. 
At this stage you will cough a little, then wash face 
and hands, and then raise up a notch higher and eat 
breakfast. Rest a while after breakfast and then 
sit up to any position you like. In this way you can 
avoid the exhausting cough which comes on if you 
sit up straight all at once. 

Fullness and Shortness of Breath on Eating. If 
you feel uncomfortably full and short of breath on 
eating, or immediately after, the following procedure 
will probably relieve you: Take four small meals a 
day, and very little liquid with your meal ; five drops 
tincture nux vomica before meals (ask your doctor 
about this) ; confine your food to cereals with little 
milk, bread and butter, fresh vegetables (except 
greens) , eggs, little meat, honey, and stewed fruits. 

Substitute for Bed- Pan. If you find the bed-pan 
uncomfortable and difficult the following substitute 
will probably be quite satisfactory: Put a chair that 
is several inches lower than the bed up against the 
bed, spread out several layers of newspaper from 
edge of bed to chair, turn on your side and allow 
buttox to extend well over edge of bed, flex your 



69 



TUBERCULOSIS 

knees up toward chest so as to imitate sitting posture, 
and you will find results very satisfactory. Use 

ordinary urinal at same time. 

Bowels. It is of great importance to keep the 
bowels well regulated — one or two normal movements 
a day being maintained. The patient should not rely 
on drugs for this purpose, but should accomplish this 
with a well-balanced diet, taking enough green vege- 
tables, such as spinach and cabbage, stewed prunes, 
honey, bran-bread, and fresh fruits to accomplish 
this end. Mineral oil, night and morning, may be 
used to supplement this regimen if necessary. It is 
purely a lubricant and is not digested nor absorbed. 
An occasional mild laxative, such as cascara, may be 
necessary; and castor oil, when occasion demands, 
has a wholesome effect. 

It is a great help and highly important to have 
a regular time for this purpose, preferably just after 
breakfast each morning. The habit can be estab- 
lished usually within a week or two. The patient 
should go to stool at the same time each morning and 
sit for 15 or 20 minutes, and if there is no movement 
he should then use a suppository or enema for a few 
times until the habit is established. 

Water. The patient should have a pitcher of 
fresh water by his bed all the time and drink freely — 
six or eight glasses a day, unless he has a heart or 
kidney complication which would contraindicate this. 
About an hour after meals and before retiring are 
the best times for drinking. A large amount of water 

70 



HELPFUL SUGGESTIONS 

tends to dilute the poisons of the disease and to wash 
them out of the system, as well as being a great help 
to the bowels. 

Mouth. "Mine own mouth shall condemn me," 
and yet the mouth is often the most neglected part of 
our anatomy. A foul mouth, pyorrhea, and decayed 
teeth not only have a very bad influence on the appe- 
tite and digestion, but may be the source of very 
serious infection in the heart or kidneys, and in 
"rheumatism." We should give careful attention 
daily to cleansing the teeth, brushing them after each 
meal, and using a good toothpaste, such as Pebeco, 
once a day, preferably at night. The mouth harbors 
many bacteria, and often pathogenic ones. If the 
gums or teeth are in poor condition it is well to use a 
potassium chlorate mouth wash several times a day, 
and to gargle with Dobell's solution morning and 
night, in addition to the care of the teeth as men- 
tioned above. 

Sleep. Some patients are inclined to wory un- 
duly because they cannot sleep as much as they think 
they should — and the more they worry the less they 
sleep. If they would only leave off the worry they 
would get all the rest they require whether they sleep 
or not, for it is possible to rest without sleep if they 
would lie in a perfectly relaxed condition physically 
and mentally. And, incidentally, such a relaxed 
attitude is the best soporific of which we know. Stop 
worrying a while and try it and see if it doesn't work ! 

71 



TUBERCULOSIS 

Amusements. Amusements are often the cause of 
set-backs in tuberculosis — probably more often than 
work. The patient must realize that amusements, as 
well as work, count on his allotted exercise, and when 
he has used up this amount in either work or play 
he cannot then go and indulge in the other with im- 
punity. Pool and billiards are bad forms of exercise 
for the consumptive; and in addition to this the 
atmosphere of the room is often vitiated by smoke, 
dust, and poor ventilation. Games of chance, how- 
ever small the stake, are too seductive and exciting 
for the "t. b," and they, together with pool and 
billiards, should be postponed for at least two years 
after the "cure." A rubber of bridge, whist, solitaire, 
42, etc., is not objectionable, if not overdone. Chess 
is too concentrating — I have seen temperature raised 
two degrees by a game of chess. It is much better to 
cultivate an outdoor hobby — an interest in plants, 
birds, landscape gardening, architecture, astronomy, 
etc., and such diversions will prove to be far more 
interesting and satisfying than those mentioned 
above. 

Food. (See Appendix for table of food values 
and vitamins.) Wherever a number of people are 
gathered together in a boarding house it is customary 
and popular to complain of the food. This habit is 
especially contagious among the sick. The situa- 
tion is further complicated by the fact that the 
demands on metabolism are increased, while at the 
same time the appetite and digestion are very apt to 

72 



HELPFUL SUGGESTIONS 

be upset by the toxines of the disease. It behooves 
the cook, therefore, to make the food as tempting as 
possible, and the patient to do his best to eat it, and 
to imitate the ox and ass in the following lines: 
"Does the ass bray when he hath grass? 
Or loweth the ox over his fodder?" 

Food is a most important factor in tuberculosis. 
It should be varied and savoury, but the use of strong 
condiments for this purpose is harmful. Milk, meat, 
eggs, bacon, butter, ripe olives, nuts, potatoes, peas, 
beans, spinach, cabbage, lettuce, tomatoes, honey, 
prunes, peaches, apricots, and fresh fruits, such as 
apples, bananas, grapes, and oranges make a good 
list to select from. Milk, meat, and eggs are the 
mainstays, and prunes and honey are excellent ad- 
juvants both on account of their high food value and 
laxative qualities. Spinach and cabbage are good 
fillers and aid the movement of the bowels by adding 
bulk to the intestinal contents. 

When repugnance to food is marked a liquid diet 
may be necessary. The following sample menu 
should be approved or modified by your doctor : 
Breakfast (About 700 calories) 

One cup ovaltine (8 ounces), contains malted 
barley, eggs, and milk. 

One glass milk (8 ounces), may use on cereal or 
crumble crackers or egg-bread in it. 

One egg (raw if necessary). 

One piece buttered toast. 



73 



TUBERCULOSIS 

Dinner (About 700 calories) 

Thick soup (8 ounces), pea, tomato, potato, etc. 

Scraped beef, or beef juice (2 ounces). 

Prune souffle, or apple sauce, with or without 
cream. 

One glass milk or buttermilk. 

One egg. 

Supper (About 850 calories) 

Gruel (4 ounces) with butter or milk, or chicken 
broth and crackers. 

Junket (4 ounces). 

One cup ovaltine. 

Malted milk flip (see below). 
Lunch (4 p.m. or bedtime, about 230 calories) 

One cup ovaltine, or glass of milk and one egg. 

A malted milk egg flip is very nourishing and 
may be taken once a day or every other day. It is 
prepared as follows : One egg, four ounces milk, two 
teaspoonfuls malted milk, vanilla flavoring, shake 
well, and then add large tablespoonful chocolate ice 
cream. If you have no shaker the egg may be 
whipped separately, the malted milk dissolved, and 
then mixed as above. 

A piece or two of candy may be taken just after 
meals, but not between meals. 

Proteins, Carbohydrates, and Fats. Foodstuffs 
are divided into three main classes, namely, proteins, 
carbohydrates, and fats. We get our supply of pro- 
teins chiefly from meat, milk, eggs, beans, and peas; 
carbohydrates from sugar, bread, potatoes, fruits, 

74 



HELPFUL SUGGESTIONS 

cereals, and milk; fats from bacon, butter, cream, 
oils, and nuts. Certain minerals are also necessary, 
chief of which are sodium which we get in common 
table salt, and calcium and iron which are found in 
meat, milk, eggs, and vegetables. Proteins are needed 
chiefly for the repair and growth of our tissue cells; 
carbohydrates and fats chiefly to furnish the fuel 
necessary for our energy. In recent years it has also 
been discovered that certain constituents of our food, 
known as vitamins, are essential to health. 

The Calory. The unit for the measure of food 
values is called the calory, which is the amount of 
heat required to raise one liter of water (about one 
quart) from degrees C. to 1 degree C., or from 
32 to 33.8 degrees F. 

1 gram* of protein = 4 calories, approximately. 

1 gram of carbohydrates = 4 calories, approxi- 
mately. 

1 gram of fat = 9 calories, approximately. 

One should try to maintain about the normal 
weight for his age and height. (See Appendix for 
table of weights.) A few pounds under or over this 
is of no consequence; but marked under- or over- 
weight (15 or 20 pounds) should be avoided when 
possible. The stuffing methods of a few years ago 
are unscientific and have wisely been abandoned. 
A marked gain in weight is not at all necessary for 
improvement, and by no means does it always indicate 
improvement in tuberculosis. 



*30 grams = 1 oz., approximately. 

75 



TUBERCULOSIS 

One should take an amount equal to 2,500 to 
3,500 calories a day, divided about as follows: 
Protein, 500 or 600 calories (125 to 150 grams*); 
carbohydrate, 1,500 to 1,800 calories (375 to 450 
grams); fat, 900 to 1,200 calories (100 to 125 
grams) ; or roughly the equivalent of one-half pound 
meat, six glasses milk, two eggs, quarter pound 
potatoes, six slices bread, two saucers prunes, and 
three squares of butter a day. The tendency in tuber- 
culosis is to eat too little, and one should see to it that 
one gets enough nourishing food to maintain one's 
weight. But remember that over-eating is as great an 
evil as under-eating. If you give an automobile too 
much gas you choke the engine. Dr. Brown well 
says, "To eat as little as will enable you to hold 
your weight and strength is the important thing." 



*1 lb. = 460 grams, approximately. 
1 oz. = 30 grams, approximately. 

76 



MISCELLANEOUS 

"Success lies not in achieving what you 
aim at, but in aiming at what you ought to 
achieve." 

The Daily Routine. The following routine has 
been found to give the best results and this, or some- 
thing similar, is in force in most sanatoria: 

7:30 Awake. Take temperature. Glass of hot 
water, or hot milk if desired. Warm water for wash- 
ing. Cold sponge if ordered. 

8:00 Breakfast. 

8:30 Evacuation of bowels. 

8 :45 Outdoors on chair, or in bed on porch. 
10:00 Exercise when ordered. 
10 :30 Extra nourishment when ordered. 
12:30 Rest, reclining on chair or in bed. 
Temperature. 

1 :00 Dinner. 

2 : 00-4 : 00 Silent rest hour, lying flat in bed or 
on chair. 

3:30 Extra nourishment when ordered. 

4:00 Temperature. Exercises when ordered. 

5 :30 Rest, reclining on chair or in bed. 

6 :00 Supper. 

6:30 Outside. 

8:00 Temperature. 

9 :00 Extra nourishment when ordered. 

9:30 Bed. 

77 



TUBERCULOSIS 

Once or twice a week hot bath followed by cold 
sponge. 

Temperature. The temperature and pulse are 
the most convenient guides for the patient. Though 
by no means infallible indices of what is happening 
in the lung, still for practical purposes they are fairly 
safe advisers. It should be understood that their 
warnings come after some mischief has been started, 
but usually in time to prevent serious damage if they 
are heeded. 

Normal Temperature. The normal temperature 
is usually given as 98.6, but this does not take into 
account the daily variation between morning and 
evening temperatures which is usually a degree to a 
degree and a half. In my experience the average 
morning temperature for afebrile patients is between 
97.2 and 98, and the afternoon temperature between 
97.8 and 98.6. Variations above and below these 
figures may, and do occur in normal healthy indi- 
viduals. 

How Temperature is Regulated. The tempera- 
ture of the body is kept constant by the circulation 
of the blood which is controlled by a center in the 
brain. In tuberculosis this brain-center is hyper- 
sensitive, or more easily irritated than in health, and 
hence does not regulate the body temperature as easily 
as in health. It is on this account that such things 
as good or bad news, games of chance, constipation 
or diarrhea, a slight cold, etc., may cause a sharp 
rise in temperature, which may worry the patient, 

78 



MISCELLANEOUS 

but should not fool the doctor, as the curve of such 
temperatures differs from that caused by tuberculosis. 

When to Take It. The temperature should be 
taken immediately on awakening in the morning 
before the mental and physical activities of the day 
are begun in order to get the lowest point. A 
temperature of 98.6 at this time usually means as 
much favor as 99.4 in the afternoon does. It should 
be taken again at 12, 4, and 8. If you have been 
free from fever for some time it is not necessary to 
keep on taking your temperature every day. Once a 
week at 8, 12, 4, and 8 will do. 

How to Take It. After exercise the patient 
should rest for half an hour before taking tempera- 
ture or pulse. Do not take either cold or hot drinks 
shortly before taking the temperature, and do not take 
the thermometer out at frequent intervals to see what 
the mercury is doing. Keep thermometer under 
tongue for five minutes regardless of whether it be a 
one- or two-minute one. In cold weather, especially 
if wind is blowing and you have been talking, keep 
mouth shut for fifteen minutes before taking tempera- 
ture. Also, warm the thermometer on top of tongue 
before placing it under the tongue. In very cold 
weather, up North and East, mouth temperatures are 
not very reliable and the temperature should be taken 
per rectum. It should be remembered that rectal 
temperatures are normally 0.6 to 1 degree higher than 
mouth temperatures. 



79 



TUBERCULOSIS 

Something or Nothing ? Before leaving the sub- 
ject of temperature I should like to call attention to a 
very common mistake that most patients and many 
doctors make when they say, "I have a temperature," 
or "no temperature" when they mean "fever" or "no 
fever." Everybody and everything has a tempera- 
ture, the atmosphere has a temperature, and hence it 
is incorrect to say "I have no temperature," and 
axiomatic to say "I have a temperature." In the 
words of Socrates, "Do I seem to say something, or 
nothing at all?" 

Pulse. The pulse is a more sensitive indicator 
than the temperature, but also a more unreliable one, 
as it is more easily effected by other factors besides 
the disease. If you could take your pulse while 
asleep it would not tell any stories, but even the mere 
act of counting it often increases the rate, especially 
in nervous patients. 

An instance. I recall how it defeated me on one 
occasion when attempting to cheat on my friend 
Bill L. Bill had a new stop watch and had collected 
a dime from most of his friends by betting them that 
they could not guess within ten seconds of a minute. 
When he made his proposition to me I thought how 
easy it would be just to count my pulse and collect his 
dime. But, alas, the excitement of this trick in- 
creased my pulse rate, and Bill increased his wealth. 
Don't bank on your pulse too much ! 

Normal Pulse. The pulse varies with age and 
with the individual. A fair average for normal is 

80 



MISCELLANEOUS 

between 70 and 80. Women have a faster pulse than 
men. In fact, the smaller the animal the faster the 
pulse. The elephant's pulse is 26 and the mouse's 
250 per minute. 

Rest. Rest is recognized now as the most im- 
portant factor in the treatment of tuberculosis. Pro- 
longed rest in bed is the quickest and surest road to 
the arrestment of the disease. It is the best measure 
to combat the toxemia, and the fever which is caused 
by it; the cough; the disturbances of digestion, and 
the increased demands on metabolism ; and it allows 
the healing process in the lungs to take place more 
quickly and with less disturbance and danger of 
back-sets. 

The popular notion that rest in bed will cause 
the patient to lose his appetite and weight and bring 
on constipation is an erroneous one. These things 
are caused by the toxines of the disease and by the 
fever, and not by the rest. When fever is present 
and the toxines of the disease are being washed out 
into the blood the demands on metabolism are greatly 
increased, while at the same time the digestive organs 
are upset and their efficiency lowered. All of which 
means more work for the heart and lungs, and under 
increased difficulties. Exercise in the face of these 
conditions is simply adding fuel to the fire. 

The amount of extra work thrown upon the heart 
and lungs by the simple exertion of sitting up, and 
still more in standing up, is astonishing. The unit of 
measure of this work is called the foot-pound, i. e., 



81 



TUBERCULOSIS 

the energy required to raise one pound one foot. The 
normal heart does about two and a half foot-pounds 
of work at each beat. The mere act of standing up 
will increase the patient's pulse usually ten beats or 
more per minute, or 600 beats per hour, which equals 
1,500 foot-pounds of extra work, or about the equiva- 
lent of bringing in an arm full of wood, a thing 
which the patient very wisely would not think of 
doing. 

Exercise. After an adequate period of rest, 
which will vary with the individual case and the 
stage of the disease, there comes a time in the course 
of treatment when regulated exercise gradually and 
systematically taken is beneficial. Exercise is "dan- 
gerous medicine" in tuberculosis, and the patient 
should no more take upon himself the responsibility 
of determining the time and amount of his exercise 
than he should of administering tuberculin to him- 
self. One's feelings are a deceptive and dangerous 
guide on this point, as the damage from too much 
exercise may not become apparent to the patient until 
days, or even weeks, after it has been done. 

For those patients on exercise the following rules 
are very important : 

Exercise means walking. Special permission 
must be obtained for any other form of exercise. 

(1) Never get tired. Always stop at the first 
symptoms of fatigue, physical or mental. 

(2) None if you are uncomfortably short of 
breath, or if your pulse is fast. Ask the doctor if 
pulse is over 90. 

82 



MISCELLANEOUS 

(3) None if your afternoon temperature the day 
before was over 99.4, or if your morning temperature 
that day was over 98.6. 

(4) None if there is any trace of blood in your 
sputum. 

( 5 ) None for one hour after meals. 

(6) No hill or mountain climbing without spe- 
cial permission. 

(7) If you are caught out in the rain don't 
hurry, never run on any account. It won't hurt you 
to get wet if you keep on walking and change your 
clothes immediately when you get home — dry your- 
self carefully with a towel, or take alcohol rub. 

(8) Exercise regularly and systematically, rain 
or shine. 

Tuberculin. Tuberculin is a two-edged sword 
which should be used only by a careful, experienced 
physician who is fully cognizant of its dangers and 
of its action, and who has a definite and intelligent 
conception of what he is trying to accomplish with it. 
The patient should be under the most careful ob- 
servation during such treatment and an accurate 
record of his pulse, temperature, expectoration, ap- 
petite, and weight kept; and the focal reaction in 
the lung carefully observed. Only in this way can 
the patient be adequately safe-guarded against the 
dangers of tuberculin. In some cases it undoubtedly 
causes marked benefit — chiefly in chronic cases that 
are at a standstill, and in early cases where the defen- 
sive mechanism of the body is capable of being 



S3 



TUBERCULOSIS 

stimulated to put forth a greater degree of resistance. 
It is also claimed by some authorities that the degree 
of immunity in children can be increased by tuber- 
culin treatment. 

The possibility of beneficial results from tuber- 
culin are based on: (1) The inflammatory reaction 
which it produces around the tuberculous foci. If 
the right degree of inflammation is produced it 
promotes the healing of the foci; too much in- 
flammation causes harm ; and too little has no effect. 
(2) The possibility of increasing one's resistance by 
stimulating cells which are capable of a greater 
response than they are giving to the stimulation which 
comes from the disease. (3) The possibility of in- 
creasing one's tolerance to the toxines of the disease. 

If a physician is not prepared, or willing, to keep 
the accurate record mentioned above, and to observe 
carefully the focal reactions, he should not give 
tuberculin; nor should the patient take it from one 
who does not observe these precautions. 

Artificial Pneumothorax. Artificial pneumo- 
thorax consists in injecting air, or gas, into the 
pleural cavity in order to collapse the lung. This 
brings about: (1) more or less complete rest of the 
lung, and allows the healing process to go on un- 
interrupted by its normal movements ; ( 2 ) a marked 
slowing of the blood and lymph flow in the lung, with 
a diminished absorption of the toxic products of the 
disease: (3) a tendency to check the spread of the 
disease, and to prevent the aspiration of infectious 

84 



MISCELLANEOUS 

material into the other lung. The effect on the 
temperature, amount of sputum, cough, and appetite 
is often very prompt and striking. This form of 
treatment sometimes brings about the arrestment of 
the disease in otherwise quite hopeless cases. 

The inherent dangers of the treatment are very 
small, if careful technique is observed. The ob- 
literation of the pleural cavity by the adhesion of the 
two pleurae, which frequently follows after the cessa- 
tion of treatment, is an objectionable feature, and 
renders it impossible to use this form of treatment 
later on if it should become desirable to do so. It is 
better, therefore, to bring about the arrestment of the 
disease without a pneumothorax if possible, and re- 
serve this measure for future emergencies. If, how- 
ever, after several months of careful treatment the 
disase is steadily progressive an artificial pneumo- 
thorax should be seriously considered, and instituted 
unless there are complications of the heart, or other 
lung, which forbid it. 

Medicines. Up to the present time no medicine 
has been found that has anything more than an in- 
direct effect in tuberculosis, and also a useful part 
in allaying troublesome symptoms. The patient 
should not take any medicine unless it is prescribed 
by his physician, and any medicine that disturbs the 
appetite and digestion should be discontinued. 

Alcohol. I take the following facts from 
"Alcohol: It's Action On the Human Organism," a 
recent Government Report by the committee of the 

85 



TUBERCULOSIS 

Liquor Control Board of England. On the committee 
were Professor Cushny, a world-renowned authority 
on pharmacology (or the action of drugs) ; Professor 
Sherington, a well-known authority on physiology; 
and Professor McDougall, of the Department of Psy- 
chology of Oxford University. There were other 
men, distinguished in business and politics, on the 
committee, but these three names guarantee the 
scientific and dispassionate nature of the report. 

"There is no evidence of injurious action of 
moderate doses, well diluted, and taken at intervals 
long enough to eliminate the effects of the previous 
one; but bad effects follow when it is not so taken. 
It is devoid of any beneficial effects in any form 
whatever, except as a narcotic in certain abnormal 
states, as excessive fatigue from loss of appetite or 
inability to sleep. 

"There is no mutual exclusion between the 
properties of a food and a drug (or poison) — alcohol 
is both. As a food it is oxidized completely, furnish- 
ing heat and energy for muscular work, but it cannot 
be stored as fats and carbohydrates are. On account 
of its drug action it can be used as a food only in a 
restricted sense — it is not a true food stuff. It has 
no accessory action on metabolism. 

"Its chief action is on the nervous system. Even 
moderate doses involve some impairment of the 
higher nervous functions. It is purely a narcotic 
and not a stimulant — the feeling of well being is due 
to a blunting of the higher faculties, and general loss 



86 



MISCELLANEOUS 

of control. Small doses have no appreciable effect 
on digestion or on the heart — larger doses depress or 
paralyze them. The feeling of warmth is due to 
dilatation of the skin blood-vessels, but the actual 
result is a more rapid loss of heat." 

In the light of these facts one must admit that it 
is much the safest policy to abstain entirely; since, 
(a) no possible good can come from it; (b) it is a 
potent factor for harm if abused, and its influence 
in this direction is subtle and hard to resist. 

Tobacco. The effect of tobacco on the appetite 
and digestion, and on the heart and blood-vessels is 
unquestionably harmful. The importance of these 
effects, however slight, is magnified in tuberculosis 
when so much depends on the proper performance of 
these functions. The toxines of tuberculosis affect 
the heart, and the nicotin of tobacco is simply adding 
fuel to the fire. The sedative effect of tobacco is 
relatively slight as compared with that of morphin 
and alcohol, and the habit can be comparatively 
easily broken by the exercise of a little will-power, 
and it is advisable for the consumptive to do this. 
In able-bodied men smoking is associated with a 
loss of lung capacity of about 10%. 



87 



PART II 
REFLECTIONS OF A DOCTOR-PATIENT 



HISTORICAL 

"T&e more attention you give to the 
tuberculosis problem the more it grows in 
size*' 

— Trudeau. 

1600 B. C. Recent investigations by paleo- 
pathologists on Egyptian mummies indicate that 
tuberculosis was a nourishing disease as early as 
1600 B. C. They advanced the interesting hypothesis 
that the Egyptians recognized the favorable influence 
of climatic resorts on this disease, basing this opinion 
on the fact that larger numbers of mummies showing 
tuberculous changes are found in certain localities 
with good climates than in other places, and assuming 
that these patients went to these places for the benefit 
of the climate. 

Hippocrates. The first accurate description of 
the signs and symptoms of tuberculosis recorded is by 
Hippocrates (460-377 B. C.) known as the "Father 
of Medicine." The belief was held by the Greeks 
at this time that this disease was contagious. 
Hippocrates left numerous writings on medical sub- 
jects. The following aphorism by him gives an in- 
teresting light on his views on medicine : 

"Quae medicamenta non sanant, ea 
ferrum sanat; quae ferrum non sanat, ea 

89 



TUBERCULOSIS 

ignis sanat; quae vero ignis non sanat, ea 
insanabilia reputare oportet." 

("What medicines do not cure, the knife 
cures; what the knife does not cure, fire 
cures; what, in truth, fire does not cure, it is 
proper to consider these things incurable.") 
Barren Period. No advance over Hippocrates' 
ideas was made for several centuries. Galen (131- 
201 A. D.) recommended the high lands of Phrygia, 
and a milk diet. Pliny's (23-79 A. D.) enthusiasm 
over the pine forests has a modern echo in the sana- 
toria located in the pine forests of North Carolina. 
Following this period there was a long barren age 
of about fourteen centuries during which no advance 
is recorded. In the seventeenth century Sylvius and 
Morton noted the connection of tuberculous nodules 
with tuberculosis. They also believed that it was 
hereditary and contagious. 

Progress in Nineteenth Century. Bayle (1810) 
was the founder of the modern pathology of tuber- 
culosis. He described accurately the stages of 
development, and recognized the miliary tubercle as 
the starting point. 

Laennec (1819), a Frenchman, recognized the 
tuberculous nature of scrofula, and gave an accurate 
description of the transformation of tubercles toward 
ulceration. His greatest gift to medicine though was 
the "art of auscultation" (the method of listening to 
the chest with a stethascope, which is today the most 
reliable method of obtaining information of what is 

90 






HISTORICAL 

happening in the chest). He was the first to recog- 
nize pneumothorax in a living patient, and he de- 
scribed accurately its physical signs. He was one of 
the great masters of medicine, although he was taken 
off by an early death from tuberculosis. 

In 1840 Dr. Bodington, an obscure practitioner 
living in Sutton Coldfield, England, published an 
essay on "The Cure of Pulmonary Consumption on 
Principles Natural, Rational, and Successful" in 
which he emphazised especially fresh air day and 
night, generous diet, and careful medical supervision. 
He stated that cold air is never too intensive for a 
consumptive, and that his apartment should be kept 
well aired. His views received very bitter and con- 
temptuous opposition. He was regarded as a lunatic ; 
his patients were driven from him, and by the irony 
of fate, he was compelled to turn his institution into 
an insane asylum. 

Virchow (1847-50), a German, added valuable 
data on microscopic studies. 

Villemin (1865-68), a Frenchman, established 
the transmissible and infectious character of the 
disease by a series of brilliant experiments on 
animals. He concluded that tuberculosis was trans- 
mitted from man to man by a "virus'' present in the 
sputum. 

Koch and the Great Campaign for the Prevention 
and Cure of Tuberculosis. The greatest name in the 
history of tuberculosis is Robert Koch, a German, 
who discovered the tubercle bacillus in 1882, grew 



91 



TUBERCULOSIS 

it on artificial media and stained it, and established 
the fact that it was the cause of tuberculosis. Dr. 
Trudeau said: "In 1882 Robert Koch announced to 
the world his discovery of the tubercle bacillus. His 
paper (probably the most far-reaching in its im- 
portance to the welfare of the human race of any 
original communication) at once threw a flood of 
light on the darkest page of medicine, a light which 
revealed the microscopic fungus which is the cause of 
tuberculosis, and gave a new impulse and opened a 
new horizon to medical thought." 

From this information and stimulus began the 
great campaign for the prevention and cure of tuber- 
culosis, with the estalishment of dispensaries, sana- 
toria, national and inter-national conferences, state 
and city laboratories where any patient can have his 
sputum examined free of charge, etc. The results, of 
this campaign have been most encouraging indeed. 
The death rate from tuberculosis in the United States 
was 254.4 per 100,000 population in 1890. In 1910 
it was 160.3 per 100,000; and in 1921 it was about 
120 per 100,000, and tuberculosis has dropped from 
first place to third place as a cause of death. (See 
chapter on Prevention and Cure.) Koch died in 
1910, and has been honored by the erection of a statue 
to him in Berlin. 

Cornet established the importance of dust from 
dried sputum as a source of infection. 



92 



HISTORICAL 

Fluegge modified this air-borne view by showing 
that the moist droplets from cough spray and sneez- 
ing was a more important source than the dry dust. 

Von Behring called attention to the alimentary 
tract as a source of infection from infected milk and 
food, especially in children. 

Sanatoria. The sanatorium idea was founded by 
Brehmer. He established at Goebersdorf, Germany, 
in 1859, the first sanatorium. He located it in the 
mountains and laid out attractive paths for his 
patients to take regular walks — a regime of graduated 
exercise after a fashion. His patients undoubtedly 
got more exercise than they should have, but this 
regulated open-air regime produced so much better 
results than were being obtained otherwise that the 
plan, in spite of much opposition at first, gradually 
became popular and highly esteemed. His distin- 
guished patient, Dr. Dettweiler, was impressed with 
the favorable influence that "rest" had upon the 
patients under these outdoor conditions, and became 
one of the earliest advocates of rest in the treatment 
of tuberculosis, which is recognized today as the most 
important factor in its treatment. 

Dr. Trudeau. Dr. Trudeau, in our country, was 
among the first to break away from the "hot-house* ' 
treatment (the plan of keeping the patient in a room 
with all the windows and doors closed, and with a 
fire going, as he describes the treatment that his 
brother received in 1865), and to advocate the outdoor 
life and open-air treatment. This he did by personal 



93 



TUBERCULOSIS 

example in going to the Adirondack^, where he later 
established the now famous Adirondack Cottage 
Sanatorium.* He also proved the advantages of 
outdoor life by the following interesting experiment. 
He infected ten rabbits with tuberculosis, rive of 
which he placed in a cellar with damp, sunless atmos- 
phere and poor food, and the other five he placed in 
a wire pen with access to the open air and sunshine. 
The results were very striking. The disease 
progressed very rapidly in the five rabbits in the 
cellar and four of them died within three months; 
while four of the five out in the open recovered. 

Otfer American Workers. Among other Ameri- 
can workers in tuberculosis who deserve mention for 
their important studies and contributions are: 
Benjamin Rush, who contributed several papers of 
importance which were among the first to be pub- 
lished in .America: Samuel G. Morton, a pupil of 
Laennec, published in 185 4 a volume on Pulmonary 
Consumption which was the first issued in the United 
States; William W. Gerhardt added important 
studies on tuberculosis meningitis; Henry I. 
Bowditch was interested in tuberculosis throughout 
his lon^ and active life, and his labors in New Eng- 



*The Trudeau School of Tuberculosis was established 
in connection with this sanatorium in 1917. Its purpose is 
to offer the opportunity to physicians to become more thor- 
oughly acquainted with the best methods of diagnosis and 
treatment of tuberculosis, and to have a little personal ex- 
perience in this line — features that have been entirely too 
much neglected by our medical schools in the past. 

94 



HISTORICAL 

land added important contributions to the disease; 
Austin Flint's contributions to the physical signs and 
symptoms of tuberculosis was a work of great merit 
and is still of value. 

National Tuberculosis Association. The Na- 
tional Tuberculosis Association was formed in 1904. 
Its purpose is the study and prevention of tuber- 
culosis. Dr. E. L. Trudeau was the first president, 
and such distinguished men as the late President 
Roosevelt and Sir William Osier have been num- 
bered among its honorary vice-presidents. Anyone 
who is interested in the campaign against tuberculosis 
is eligible for membership, and the dues are five 
dollars a year. Many valuable pamphlets and litera- 
ture on tuberculosis are supplied to members free of 
charge, including the monthly magazine, "The 
Journal of the Outdoor Life." The address of the 
Association is 370 Seventh Ave., New York. 

It has promoted and stimulated the organized 
movement against tuberculosis in every possible way. 
Some of the notable achievements are: 

(1) Organized and conducted the Sixth Inter- 
national Congress of Tuberculosis at Washington in 
1908. 

(2) Started the first travelling tuberculosis ex- 
hibit, and continued it for eight years. This exhibit 
demonstrated the value of this method of education, 
and resulted in the creation of thousands of similar 
exhibits, large and small. 



95 



TUBERCULOSIS 

(3) Promoted the Red Cross Christmas Seal from 
a limited sale of 30,000,000 in 1910 to 200,000,000 
in 1917. 

(4) Printed and distributed educational leaflets, 
posters, and booklets on tuberculosis aggregating sev- 
eral million copies. 

( 5 ) Established the American Review of Tuber- 
culosis, the only strictly scientific journal on tuber- 
culosis published in English in America. 

(6) Established the Framingham Health and 
Tuberculosis Demonstration. 

( 7 ) Co-operated with the American Medical As- 
sociation in exposing "fraudulent cures" for tuber- 
culosis. 

(8) Promoted the organization of state and 
county associations and co-operated with them in es- 
tablishing dispensaries, visiting nurses, and sanatoria. 

(9) Rendered valuable aid to the Government in 
handling the tuberculosis situation during the war. 

Tuberculin and Artificial Pneumothorax. In 
addition to the "rest-hygienic-dietic-open-air" treat- 
ment which has been developed in the last twenty-five 
or thirty years two other measures stand out above 
all other remedies that have been tried during this 
time, namely, tuberculin and artificial pneumothorax. 
Koch discovered tuberculin in 1890 and there have 
been vigorous controversies as to its therapeutic value 
since then. The consensus of opinion of those who 
have studied tuberculin most carefully is that it is of 
definite value in certain selected cases when admin- 



96 



HISTORICAL 

istered by one who thoroughly understands its limita- 
tions and dangers. As a diagnostic test it is of the 
greatest importance, both in human beings, and more 
especially in testing dairy cattle. 

Forlanini, an Italian, first suggested the use of 
artificial pneumothorax in 1882, i. e., the method of 
injecting air into the pleural cavity in order to 
collapse the lung and give it absolute rest. He first 
tried it in 1892, and reported a case successfully 
treated in 1894. Dr. Murphy, of Chicago, in 1898 
independently conceived the idea, and reported five 
cases so treateed. Since that time many thousands 
of cases have been so treated, and many of them have 
received striking benefit and recovery. 

Tuberculosis — Extent, Races, Animals. Tuber- 
culosis has claimed the greatest total of victims of 
any disease, although in the last few years it has been 
reduced from first place to third place as the cause 
of death, and is still falling and will continue to fall 
as the methods of prevention become better known 
and universally adopted, and the earliest possible 
diagnosis and treatment instituted. It exists in all 
latitudes and altitudes and climates, but is most 
prevalent in temperate zones and lowlands. This is 
accounted for largely by the fact that the population 
is more dense in these regions, and consequently the 
environment more unsanitary. All races are subject 
to it. The Indians, Negroes, Hawaiians, Australian 
Bushmen, and all primitive races seem more sus- 
ceptible, or at least succumb more readily to it, than 

97 



TUBERCULOSIS 

the white European races who have been associated 
with it many centuries, and have developed a relative 
racial immunity. It is practically unknown in wild 
animals and birds, because they are not in contact 
with the bacillus, but when they are kept in captivity 
they develop it. All domestic animals and birds are 
liable to infection. Dairy cattle and swine are the 
most susceptible, and investigations have found as 
high as 10 to 15% of dairy cattle infected in some 
regions. Sheep, goats, horses, dogs, cats, rats, and 
mice are more difficult to infect, and seem to have a 
fairly high degree of iinmunity. 

Types of bacilli, Three types of tubercle bacilli 
are distinguished: human, bovine, and avian. The 
human type is the most virulent for human beings; 
the bovine type most virulent for mammals; it is 
difficult to infect mammals with the avian type. 



98 



*^. II *^r* 

PHYSICIAN AND PATIENT 

"... The secret springs of action 
Which lie between the surface and the show 
Are disregarded; with self-satisfaction 
We judge our neighbors, and they often go not 
understood." 

When thou feelest sick call upon God, and bring 
the physician; for a prudent man scorneth not the 
remedies of the earth." The same author^ a con- 
temporary of Hippocrates (about 400 B. C), also 
says, "The skill of a physician shall lift up his head, 
and in the sight of great men he shall be in admira- 
tion." 

Physicians at this time seem to have been held in 
high esteem. They were required to sign the Hippo- 
cratic Oath, which indicates an effort to maintain a 
high standard in the profession, and to exclude 
charlatans and quacks who seem to have been 
numerous in those days, and are still with us owing 
to the laxness of our laws in regard to such parasites. 
The oath is partly as follows: "I swear by Apollo 
. . . and by Aesculapius . . . that I will 
follow that system of regimen which, according to my 
judgment, I consider for the benefit of my patients; 
and abstain from whatever is delerterious and mis- 
chievous ; . . . With purity and with holiness I 
will pass my life and practise my art. . . . 

99 



TUBERCULOSIS 

Whatever . . . I see or hear I will not divulge, 
as reckoning that all such things should be kept 
secret. . . . " An excellent motto for today. 
and some physicians still adhere to it. 

Qualifications of Physician, The important 
thing for the patient now is to "bring" a competent 
physician. The one who undertakes to treat tuber- 
culosis should have not only a comprehensive knowl- 
edge of the disease, but also a thorough understand- 
ing of human psychology. He must remember that 
he is dealing with human beings, and not with ex- 
perimental rabbits. And above all he must have 
firmness and personality enough to make the patient 
and attendants co-operate in the treatment. Mutual 
interest, sympathy, and kindness is a much more 
satisfactory policy than compulsion. But some few 
patients have the attitude of the Irishman toward 
volunteering, who, when asked why he did not 
volunteer for the army, said : ''Sure it's me who would 
go willingly if they would only compel me. v 

When other things are equal the more optimistic 
and enthusiastic the physician and patient are the 
better will be the results. In such a tedious and 
chronic disease as tuberculosis, patience, courage, and 
character are large factors in the outcome. Since 
there is as yet no specific remedy, such as quinine in 
malaria or serum in diphtheria, we must make use of 
every possible aid however small it may seem, and 
indifference must be replaced by interest and hope. 



100 



PHYSICIAN AND PATIENT 

Mutual Understanding. I quote the verse at the 
head of the chapter to show the relationship which 
should not exist between physician and patient. If 
the best results are to be obtained in any given case 
there must be a mutual and sympathetic understand- 
ing and interest between physician and patient, and 
perfect candor in all matters. It is very easy for 
the patient to mislead the physician by giving him 
false information, or by withholding information, 
but such a course works harm only to the patient. I 
have seen patients do things which they knew they 
should not do, and then put down on their charts a 
normal temperature and pulse when they had fever 
and an increased pulse rate, in order that the 
physician might not suspect that they had disobeyed 
instructions. If they could fool the disease as well 
as the physician by such a course it would be well 
and good, but they should not be deceived, the disease 
is not mocked, and they will have to reap what they 
sow. Success depends on thorough co-operation of 
physician and patient, and a larger share of the 
responsibility rests with the patient, for if he does not 
carry out faithfully his instructions the best advice is 
only wasted on him. 

Confidence Necessary. Full confidence in the 
physician is necessary if the best results are to be 
obtained. If this is not possible it is an injustice 
both to the physician and to the patient to remain 
under his care. It is therefore better to go to another 
physician in whom you have complete confidence and 

101 



TUBERCULOSIS 

with whom you will co-operate fully. 

Co-operation. Proper and successful co-opera- 
tion depends on intelligence, close attention to details, 
and individualization. The patient should have a 
definite idea of why he is called upon to forego cer- 
tain apparently harmless pleasures, to endure priva- 
tions and hardships, and to adhere to a certain regime 
of treatment. The physician should not ask nor ex- 
pect him to carry out measures faithfully for which 
he can give no adequate explanation. There are no 
grounds for secrecy in this disease, and the "take this 
medicine and ask no questions" attitude is a relic 
of supernaturalism and savors of quackery. The 
patient should be acquainted with the course of the 
disease, and prepared for the ups and downs that 
are sure to come if the disease is advanced. These 
periods of activity should not be called by misleading 
and euphemistic names, but should be explained on a 
physiological and pathological basis, and the patient 
should know that they are often unavoidable and not 
incompatible with a satisfactory progress toward 
recovery. His doubts and fears should be met in a 
sensible manner by the physician, and not left to the 
false explanations and meddlesome advice of his 
neighbors. 

Candor. The dealings between physician and 
patient should be marked by perfect candor. The 
patient should know the truth, and be prepared to 
receive it and carry out instructions. Anxious 



102 



PHYSICIAN AND PATIENT 

friends and relatives sometimes request the doctor 
not to tell the patient if he finds evidence of tuber- 
culosis. And later when the patient finds it out he 
says with regretful tone, "How differently I would 
have acted if I had only known." The patient should 
know that in early cases several months of treat- 
ment are necessary, followed by many months of 
careful living; and in advanced cases many months 
of treatment will probably be necessary. He should 
know that it is a preventable, communicable, and 
curable disease. 

Dr. Pottenger, who has had over twenty years' 
experience in treating tuberculosis, says: "I have 
never yet seen a patient who was seriously injured by 
telling him, in a proper and humane way, that he had 
tuberculosis. Imagine a physician telling his patient 
with appendicitis that he has 'cramps' or 'colic'! 
Imagine what his surgeon friends would say! Yet 
many of these same surgeons are informing their 
tuberculous patients that they have 'weak lungs,' 
'throat trouble,' and other equally deceptive condi- 
tions. It is not sparing the patient to withhold from 
him the diagnosis of early tuberculosis and allow 
him to progress to an advanced condition. The 
patient's interests, as well as those of his associates, 
demand that the truth be known." 

Caveat, Doctor. As a physician who has been in 
the pew of a patient for five years let me beseech some 
of my former colleagues to be more considerate about 
adding unnecessary expense to the patient's already 

103 



TUBERCULOSIS 

overburdened budget. The time is passed for pre- 
scribing useless drugs merely to make the patient 
think that something is being done. Explanation and 
education are better and much cheaper. Consider! 
twenty dollars worth of antiphlogistine prescribed in 
one month by a well-known "specialist" for a patient 
who was making heavy financial sacrifices to remain 
under his care (this happened to my next door neigh- 
bor) — caveat, doctor, the layman is becoming 
educated ! 



104 



*^. Ill '<&* 

PHTHISIOPHOBIA AND THE CARELESS 
CONSUMPTIVE 

"O wad some power the giftie gie us 
To see ourselves as ithers see us! 
It wad frae mony a blunder free us, 
An' foolish notion." 

— Burns. 

Ignorance and Selfishness. Phthisiophobia, or 
an unreasonable fear or tuberculosis, is based on 
ignorance and selfishness, and is responsible for much 
undignified conduct and inhumanity towards careful 
and conscientious consumptives. It may be taken as 
a partial index of general ignorance concerning tuber- 
culosis. Such an attitude has caused some patients 
to become unduly sensitive about taking the necessary 
precautions against the spread of the disease, and it 
has induced others, less scrupulous, to attempt to con- 
ceal their disease by failing to observe any precau- 
tions which might attract attention to themselves. 
The remedy for these unnecessary evils is an intel- 
ligent and humane attitude both on the part of the 
public and on the part of the consumptive. We need 
a campaign of education that will protect the cleanly 
consumptive from prejudice and ostracize the careless 
man — not only consumptive, but also the careless and 
promiscuous spitter, and the individual who coughs 
and sneezes in the presence of others without covering 

105 



TUBERCULOSIS 

his mouth and nose when he has a cold, bronchitis, or 
other respiratory infections which are much more 
easily contracted than tuberculosis. 

No Danger to Adults. Adults have a marked re- 
sistance to tuberculosis, and their disease probably 
always comes from old foci acquired in childhood, 
and not from ordinary contact with consumptives. 
There is certainly no danger to the adult from a care- 
ful, cleanly, conscientious consumptive. The last war 
has offered unprecedented opportunities to observe 
the effects of the close association of tuberculous 
soldiers with healthy ones. Colonel Bushnell says: 
"Here is an experiment on a large scale; thousands 
of consumptives were put in closest contact with mil- 
lions of healthy soldiers, and the result after four 
years is that it cannot be shown that such proximity 
did the well men any harm." 

Children. For infants and children, however, 
there is real danger, and no precautions are too great 
for them. They should be most carefully protected 
from repeated and massive infections, and should live 
under the best hygienic conditions possible, as re- 
gards fresh air, sunlight, and good food, in order 
that they may be able to convert any slight infections 
which they may get into beneficent vaccinations which 
will increase their immunity to the disease. These 
precautions for children, however, in no way justify 
healthy adults in inconsiderate selfishness for their 
own safety (which is not in danger) and social and 
business ostracism which is sometimes practiced. I 



106 



PHTHISIOPHOBIA 

quote the following from a pamphlet issued by the 
National Tuberculosis Association: "The best pre- 
ventive measures against infection for those around 
the patient are healthy bodies and cheerful minds. 
. . . There need be absolutely no danger to any- 
one living with him, . . . and it is entirely un- 
necessary as well as very cruel to treat these patients, 
as is so often done, as though they had small-pox 
and could infect you at once." 

Inconsiderate and Ignorant Fears. I mention the 
following absolutely unnecessary inconvenience and 
additional expense to which I was subjected by col- 
lege students (not primitive, superstitious indivi- 
duals, mind you, but inconsiderate, ignorant college 
students in the year of our Lord 1918). I sent for 
the college barber (about two blocks distant from my 
home) to cut my hair, and he sent word that per- 
sonally he was not afraid to cut my hair, but that 
the students had told him that if he did they would 
not patronize him any more. And so I had to send 
into the city (six miles) for a barber. 

In 1803 Chateaubriand wrote in Rome: "I am in 
great difficulty; I had hoped to get two thousand 
crowns for my carriages, but, by a law of the time of 
the Goths, consumption is declared in Rome a con- 
tagious disease and as Madame de Beaumont drove 
two or three times in my carriages nobody is willing 
to buy them." 

George Sand wrote in 1839 of Chopin, with 
whom she was travelling: "Poor Chopin, who had 



107 



TUBERCULOSIS 

had a cough since he left Paris, became worse. We 
sent for a doctor — two doctors — three doctors — each 
more stupid than the other, who started to spread the 
news in the island that the sick man was a con- 
sumptive in the last stages. . . . We were re- 
garded as plague-infected; and, furthermore, as 
heathen, as we did not go to mass. The owner of 
the little house which we had rented turned us out 
brutally ... at Barcelona the landlord de- 
manded to be paid for the bed on which Chopin had 
slept, on the pretext that it must be burned." (Chopin 
did not die until ten years later.) 

No Mental and Moral Perversion. Dr. Knopf 
has called attention to the unjust criticism that con- 
sumptives are afflicted with mental and moral abera- 
tions, and so deserve social ostracism on this ground. 
He quotes the opinion of the leading physicians who 
have had large experience with consumptives, and it 
is hardly necessary to add that they all deny these 
charges. Dr. Osier said: "I have never noticed 
among consumptives any greater tendency to im- 
morality or crime than in other individuals. I should 
rather say the contrary. ... I should say 
emphatically that the average consumptive is neither 
inclined to brute selfishness nor any special distortion 
of the ethical perceptions." Dr. Trudeau said: "I 
have seen all the finer traits of human nature 
developed to the fullest extent by the burdens which 
chronic and fatal illness, often slow in its progress, 
adds to the sum total of what men and women usually 

108 



PHTHISIOPHOBIA 

have to endure in life. I have seen certainly more 
patience, courage, self-denial, and unselfish devotion 
to others in consumptives than I have noticed in the 
majority of healthy human beings. . . . History 
is full of instances which prove that tuberculosis does 
not interfere with the development to the highest 
degree of the intellectual, the moral, and the ethical 
sides of man's nature." 

Stupid Prejudice. One often meets insane pre- 
judice and near-sighted opposition to the establish- 
ment of a sanatorium on the part of town and village 
boards. And yet it has been proven over and over 
that sanatoria are a great help for a community in- 
stead of a danger. In the two German villages of 
Goebersdorf and Falkenstein, where the first sana- 
toria were established, and where five of the most 
flourishing institutions have existed for fifty years or 
more, the mortality from tuberculosis among the in- 
habitants has decreased by one-third. This is due 
to the fact that the villagers voluntarily imitate the 
hygienic precautions which are in force in the sana- 
toria. And Saranac Lake has become quite a flourish- 
ing locality since Dr. Trudeau established the Adiron- 
dack Cottage Sanatorium there, increasing from a 
tiny village with a saw mill, a small hotel for guides, 
and a few scattered houses, when he went there, to a 
modern health resort of about 6,000 inhabitants. 

Saranac Lake. In a recent careful survey of 
Saranac Lake, where 20% of the population have 
tuberculosis, Mr. Ames has shown that outside of 

109 



TUBERCULOSIS 

tuberculous families the infection of the resident 
population is less than in the average community. 
And he says : "Educational influence emanating from 
near-by sanatoria, and locally the 'open door' for the 
tuberculous into unrestricted industrial and social 
activities have done much to remove fear and igno- 
rance and to create an intelligent public mind toward 
the disease. With this sane attitude existent the 
problems connected with the control of tuberculosis 
are becoming less and less difficult of solution.." 

Summary of Evils. The Swedish National 
Tuberculosis Association has summarized the evils of 
phthisiophobia as follows: 
Phthisiophobia 

— paralyzes the struggle against tuberculosis. 

— renders all measures against tuberculosis more 
difficult. 

— facilitates the spread of infection. 

— causes us to overlook the real danger. 

— is a sign of shameful cowardice. 

— causes cruel behaviour to consumptives. 

— is an enemy to society that must be opposed. 

The Careless Consumptive. The habitually care- 
less, incorrigible, and vicious consumptives should 
not be tolerated. They are public nuisances and 
dangers to the community and should be forcibly 
segregated. The International Congress on Tuber- 
culosis held in Washington in 1908 unanimously 
agreed that the one great essential for the prevention 
of tuberculosis is proper control of all open cases 

110 



PHTHISIOPHOBIA 

(i. e., cases with bacilli in sputum), including for- 
cible segregation of those who cannot be kept under 
proper control in their homes. And yet only four of 
our states have passed any special laws looking 
toward the segregation of the criminally careless con- 
sumptive^ — New Jersey in 1911, and New York, Wis- 
consin, and Minnesota in 1913. (Pamphlet 104, 
recommended in Bibliography at end of this book, 
gives details of these and other laws on tuberculosis.) 

Dr. David R. Lyman in an excellent article on 
"The Control of the Careless Consumptive" in the 
March, 1918, number of the American Review of 
Tuberculosis cites a number of cases in point. 

Case 7. Married man with wife and two young 
children ; man positive case, and no precautions what- 
ever taken by patient or any of family. Patient 
refused any kind of treatment. All four slept in 
same bed. 

Case 2. Married women; open case; refused 
sanatorium treatment, and refused to observe ordinary 
rules of cleanliness — spits on floor, etc. The visiting 
nurse stated, "Her two children had the measles when 
I called, and the little boy was in bed with his 
mother." 

Case 10. Girl; open case; immoral character; 
refuses sanatorium treatment; and other children in 
family, probably tuberculous, not allowed to be 
examined. It is easy to see what a menace she is to 
any community. 



Ill 



TUBERCULOSIS 

Case 3. Peter , man who bums around 

town, spitting any and everywhere; was at a sana- 
torium, but was discharged on account of his in- 
tolerable conduct ; now roams around and does as he 
pleases. 

And he asks, "What is the use of continuing to 
close the stable after the horse has gone ? Why spend 
our taxes caring for the developed active case in the 
adult and permit this continued inexcusable infection 
of children to go on ? . . . we must begin at once 
to work for the provision of quarters where these 
cases can be committed by the health officer for such 
time as he decides the safety of the public demands." 

We know that it is such cases as these mentioned 
above that are infecting helpless children every day; 
and we know that it is necessary to control by force 
such cases if we are to prevent the spread of tuber- 
culosis, and ultimately eradicate this preventable 
disease. The cost of enforcing necessary preventive 
measures, and of maintaining institutions for the 
segregation of the careless, or homes for the proper 
care of exposed children, would be no more than the 
present cost of caring for indigent consumptives. And 
it would be a gradually diminishing cost, instead of 
a gradually increasing one as it is now. But we still 
lack the public sentiment and legislation necessary 
for the accomplishment of these ends. Can anyone 
continue to claim, with the least shadow of justice, 
that the right of the adult to do as he pleases is 
greater than the right of the child, who cannot deter- 
mine its environment, to be protected from this adult 
— even though it be his parent? 
112 



*^ IV *fc* 

HEALTH VS. PATENT MEDICINES, CHAR- 
LATANS, AND CHRISTIAN SCIENCE 

"Give me health and a day, and I will 
make the pomp of emperors ridiculous." 

— Emerson. 

"The American people like to be 
frazzle-dazzled." 

— Barnum. 

Health is the foundation of success and the key- 
stone in the arch of happiness. The bloom and 
buoyancy of health aid greatly in camouflaging 
physiognomic and mental defects, and render conta- 
gious the good fellowship and contentment of its 
possessor. It is passing strange that most of us take 
no thought of such a vital factor and have no intelli- 
gent plan for conserving this most valuable asset. 

In the matter of investing a hundred dollars, or in 
a conflict with the law, we seek the advice of one 
qualified by special training and experience to give 
an intelligent opinion; but when signs of failing 
health appear we are willing to take the advice of a 
deluded ignoramus whose vacant countenance and 
grateful smile beam upon us from above an adver- 
tisement and assure us that Tanlac has cured his 
stomach trouble, or that Sarsaparilla keeps his 
blood so pure that no malicious germs can obtain 
board and lodging in his tissues. Nuxated Iron 
enabled Jess Willard to lick Jack Johnson, and so 

113 



TUBERCULOSIS 

steadied Ty Cobb's nerves that he reached the dizzy 
heights of leading the American League batting 
average. (Query: What enabled Ty to lead the 
batting average for about ten consecutive years before 
Xuxated Iron discovered him? And why did it fail 
Jess so miserably in his encounter with Jack Demp- 
sey?) It is worth noting that the Journal of the 
.American Medical Association has collected and pub- 
lished at least three testimonials on Tanlac which 
were published after the patient had died from the 
disease of which the testimonial states that Tanlac 
has completely relieved him. 



TANLAC 



ffiolpoke Xlatlp &rangcrtpt 

HOLYOXE DAILY TRANSCRIPT, FRIDAY, MAY 11. 1917 — 20 PAGES 

THREE IX OXE FAMILY FUNERALS 

MAXES UNUSUAL CASE WICK-The funeral of 

Fred Wick was held this 

South Hadlev Falls Man Re- morning from his home, 

lieved of S'tomach Trouble Granby Road South Hadley 

Since Taking '"Tanlac,'' Falls, 
the X'ational Tonic 

Two clippings from the 
::■■:■; 5-zcer! 

I have gained 10 pouxds ne says "Tanlac" relieved 

Says Fred Wick, and My Mr _ Wkk of "^0^^ 

Wife and Son are Also trouble." 

Taking Tanlac and Have Tlie ' otheT sh ov , s th2Lt ■ Mlm 

Been Greatly Benefited W ick -,- 5 decd cnd bur i ed! 



Which do you believe? 
— Ed. Poster by Am. Med. Assoc. 

114 



HEALTH VS. PATENT MEDICINES, ETC. 

Patent Medicines. Patent medicines all have 
practically the same ingredients, namely, a narcotic, 
a laxative, and a bitter. These three "stand-bys" are 
advertised to cure everything, and especially "in- 
curable diseases." The following story which sheds 
real light on the morals and sincerity of at least two 
opulent harpies of the trade came to light several 
years ago. One of them proposed a bet with the 
other that he could first prepare a medicine and then 
obtain testimonials (without pay) stating that the 
medicine had cured any disease which the party of 
the second part might be pleased to name. Large 
stakes were put up, the "medicine" was advertised, 
and the testimonials gathered in — and in addition to 
winning the bet the medicine was a financial success. 

ALCOHOL COMPARISONS 

1917 



BEER 


(4J4%) 


!■ 


CHAMPAGNE 


(10%) 


mm* 


SWAMP ROOT 


(9%) 


mm 


s. s. s. 


(15%) 


■■■■ 


VARNESIS 


(15%) 


■mn 


PINKHAM'S VEGET. COMP. 


(15%) 


mmam 


PEPTO-MANGAN 


(16%) 


wm^m 


HOOD'S SARSAPARILLA 


(1654%) 


— 1 1 


TANLAC 


(18%) 


tamoa 


VINOL 


(18%) 


■■BBH 


MANOLA 


(18%) 


mmmma 


PERUNA 


(20%) 


amn^m 


WINE OF CARDUI 


(20%) 


mu^juimm 


PLANT JUICE 


(20%) 


jjmikMM«mi 


HOSTETTER'S BITTERS 


(25%) 


H^HSBH 



-Ed. Poster by Am. Med. Assoc. 
115 



TUBERCULOSIS 

The chief effects of patent medicine upon the 
patient are due to the psychic element which is stimu- 
lated by the extravagant claims, fraudulent adver- 
tising, and testimonials emanating from deluded 
ignorance and well-greased palms. But, of course, 
these effects are only temporary if the patient has real 
organic trouble. Dr. Martin demonstrated this 
psychic effect in a well-known experiment on some of 
his tuberculous patients. He led them to believe that 
a wonderful serum for the cure of tuberculosis had 
been discovered, and then injected them with a com- 
mon salt solution. A marked improvement in sub- 
jective symptoms and feelings was noted, and when 
the injections were discontinued a return of the old 
status appeared. It is this psychological element 
which makes consumptives pitifully easy victims for 
those parasites who advertise worthless consumption 
cures. 

TESTIMONIALS ARE WORTHLESS 

The subjects of these testimonials for a "consumption 
cure" all died of consumption. (Original poster shows five 
photos with testimonials.) 

These testimonials were honestly given. The consump- 
tive optimistic over a new treatment believes he has been 
benefited. Then the testimonial is secured. The victim dies 
but his testimonial lives on! 

Quacks and nostrum exploiters find no difficulty in get- 
ting chemist's certificates — of a kind ! Here is the kind fur- 
nished by W. H. Morse for cures for consumption, epilepsy, 
blindness, etc. 

"F. S. Sc. (Lord)" after one's name looks imposing. It 
costs $5.00. 

— Modified from Ed. Poster by Am. Med. Assoc. 

116 



HEALTH VS. PATENT MEDICINES, ETC. 

The patent-medicine fraternity have shown them- 
selves to be absolutely unscrupulous in their methods 
and conscienceless exaggerators and prevaricators in 
their advertisements. Several hundred "cures" are 
being exploited for diseases which are absolutely 
beyond the reach of drugs. Our trademark laws give 
these proprietors a perpetual monopoly which makes 
extensive advertising profitable, and leads to the 
great abuses which make patent medicines a menace 
to public health. Modern advertising methods seek 
to make the well man believe that he needs a "puri- 
fier" or stimulant, to cause those suffering from 
trivial ailments and dose itself unnecessarily and 
the sick believe that these medicines are panaceas 
for whatever ails the public. No one has the moral 
right, nor should he have the legal right, to sell 
products under grossly exaggerated and false claims, 
so as to induce the public to magnify imaginary and 
trivial ailments and does itself unnecessarily and 
indiscriminately. Medicines for self-treatment should 
not be secret preparations, should contain no danger- 
ous or habit-forming drugs, and should not be recom- 
mended for diseases that are obviously too serious 
for self-treatment. Yet these very things furnish the 
life-blood of the obnoxious business. (Such remedies 
for home use are included in the U. S. Pharmacopeia 
and are available for the public if they only knew it 
and would call for them.) 

If all patent medicines were abolished not only 
would the general health be improved, but the people 

117 



TUBERCULOSIS 

would be saved over SI 00,000.000 annually, and, 
most important of all,, those suffering from serious 
troubles would not reduce their chances of recovery 
by delaying proper treatment through trying out 
worthless medicines first. True, the newspapers 
would lose S40.000.000 or more per annum in adver- 
tisements, but their gain in self-respect should be 
more than worth it. 

Charlatans. Where the qualified physician is 
compelled by knowledge and truthfulness to be con- 
servative and indefinite as to promises of cure, the 
quacks are most cocksure in their false assurances. 
As proof of their claims they offer the testimonial of 
some vain woman who received a bonus of a few 
photographs for sending one along with her testimony, 
or that of a renegade doctor who is well paid for his 
lies. The patient should not be misled by these, but 
should recognize a sure signs of quackery any dis- 
play of testimonials, claims of a new discover}' or 
"special methods," form letters, and special and 
reduced rates. 

When such different agents as a dose of medicine, 
a massage, an electric magnet, a blest handkerchief, 
or Christian Science are supposed to relieve the 
same malady it should be evident that none of them 
has a specific effect on the malady, but that it is 
relieved by natural methods in due course of time. 
About eighty-five per cent of people will recover from 
their troubles regardless of what is done for them, 
and so this gives the quacks, patent medicine 

118 



HEALTH VS. PATENT MEDICINES, ETC. 

vendors, faith and mental healers a pretty good 
percentage to point to as "their cures." But in every 
serious organic trouble such as tuberculosis, nephritis, 
cancer, heart and blood-vessel diseases, etc., patent 
medicines and quacks are positively harmful, and 
Christian Science becomes harmful in keeping such 
patients away from the proper medical advice and 
treatment. 

The guardian and adviser on matters of health 
should have a minimum training of four years high 
school, two years college, four years medical school, 
and one year hospital experience, and should not be 
bound by the narrow tenets and practices of any 
system such as Osteopathy, Christian Science, Chiro- 
practic, et al., but should have an unprejudiced mind 
toward any measure that might prove helpful. Only 
such a qualified adviser should decide whether the 
patient needs a dose of medicine, an Osteopathic rub, 
Christian Science gas, an operation, or any definite 
regime of treatment. 

Christian Science. Mrs. Eddy, a firm believer in 
malicious animal magnetism (sometimes known as 
witchcraft), suffering from delusions of persecution, 
discharging and bringing suit in turn against three 
of her associates for "wishing evil" on her, sued by 
her own son on grounds of insanity, too busy to save 
her husband's life who, according to her own written 
statement, died from absorbing evil thoughts aimed 
at her by her enemies, was the human paragon chosen 
by God to reveal His methods of healing to man- 



119 



TUBERCULOSIS 

kind — methods which Christ used, but forgot to 
impart to His disciples, as one would infer from the 
preface to Science and Health. 

Just why He waited over eighteen hundred years 
to correct this oversight, and until she was well past 
middle age and had been an irascible neurasthenic 
for several years and a patient of Dr. Quimby's, who 
used "mental suggestion" in treating her, she does 
not say. Anyway, after her association with and 
treatment by Dr. Quimby, who used hypnotism and 
mental suggestion in treating many of his patients, 
the "light" dawned upon her, and she was quick to 
capitalize credulity and hope by bolstering it up with 
a religion. 

"E'en ministers they hae been kenn'd 
In holy rapture, 
A rousing whid at times to vend, 
And nail't wi' scripture." 

Dr. Wm. J. Mayo says, "Among all peoples in all 
times, the prevailing religion has been successful in 
relieving sickness, so far as mental suggestion could 
give comfort or indirectly affect the physical condi- 
tion. Christian Science has capitalized and commer- 
cialized the mentally healing virtues of Christianity." 

If their healers would acknowledge their limita- 
tions and confine their attempts to the benefits that 
come from mental suggestion, and not try to treat 
serious organic troubles, except under the direction of 
a qualified physician, their efforts would be laudable. 
The benefits of Christian Science are explainable on 

120 



HEALTH VS. PATENT MEDICINES, ETC. 

physiological grounds, and not on the basis of being 
in "perfect attunement" with the Divine "Spirit." 
The beneficial influence of the mind (cheerfulness, 
hope, courage) has long been recognized in medicine, 
and used before Mrs. Eddy "borrowed" the idea from 
Dr. Quimby. . 

The situation is stated tersely by Drs. Fisher and 
Fisk: "They sometimes succeed in the 'real cure of 
imaginary ailments,' and the 'imaginary cure of real 
ailments.' In the latter case the mental contentment 
lasts only until the real ailment becomes too aggres- 
sive to be ignored." It is in such cases that their 
meddlesome interference and unfortunate influence is 
harmful. It is criminal to withhold operation, or 
radium or x-ray for cancer at the earliest stage pos- 
sible ; to tell a consumptive in the early stages of the 
disease that his trouble is all in his mind and have 
him go about his work as usual and thus reduce his 
chances of securing an arrest of the diseases to almost 
nothing; to give a diabetic or nephritic any and 
everything he may want to eat, etc., ad mortem. 

Even more pernicious is the opposition of Chris- 
tian Scientists to measures against preventable 
diseases and hygienic living. In truth, if they had 
their way, we would have a return of the scourges 
of the dark ages. Small-pox, plague, malaria, 
typhoid, typhus, dysentery, etc., would rage and 
flourish unopposed, while they sat by and impotently 
read Science and Health to the victims — or probably 
fled to distant parts and gave "absent treatment." 

121 



TUBERCULOSIS 

Such procedure is not essentially different from that 
of the "medicine man" of savage tribes who decorates 
himself in frightful garb and beats upon his tom- 
tom to drive away the evil spirits, except that the 
noise of the tom-tom is replaced by the vaporous 
verbiage of Science and Health. 

Signs of the Time. It is encouraging to turn 
from these small groups of misguided, credulous, 
and essentially ignorant faddists who are opposing 
progress toward the goal of public health, "On which 
rests the happiness of the people and the power of a 
country," and read the signs of the time in the in- 
creasing popularity of sleeping porches and hygienic 
living and working quarters; the pure food laws, 
and demand for uncontaminated water supply, certi- 
fied milk and inspected meat; and to note the en- 
lightened opinion behind the organized campaign to 
protect the youth from contagious diseases. 

Temperance, good food, regular bowels, avoid- 
ance of prolonged physical and mental over-strain, 
proper amount of rest, recreation, fresh air, and a 
cheerful and serene disposition, together with periodic 
physical examinations, are the chief preventive 
measures against disease and old age. 



122 



<*n. V 'u& 
TEMPERAMENTS AND TUBERCULOSIS 

"I like the man who faces what he must 

With step triumphant and a heart of cheer, 
Who fights the daily battle without fear, 
Sees his hopes fail, yet keeps unfaltering trust" 

The chief difference between human machines 
and other awe-inspiring mechanisms created by the 
genius of man lies in their reacting power. No two 
human temperments will react alike to any given 
stimulus, and the same individual will vary accord- 
ing to circumstances. It is not surprising then that 
such a spectre as tuberculosis should cause all manner 
of reactions exemplifying those immortal words, 
"What fools ye mortals be." 

Fear seizes one; a vision passes before his eyes, 
and he is ready to give up the ghost. Folly per- 
suades another to take "one last fling," which may 
add many months to his period of "chasing the cure." 
Shortsightedness tells one he can't afford to stop now, 
but fails to add that it will take ten times as much 
time and money if he waits for the breakdown to 
come. Discouragement beclouds good judgment, and 
adds, "What's the use, I don't care what happens." 
Wisdom lingers with a few and says, "It's bad enough 
to lose your health; don't make the situation worse 
by losing your head." 



123 



TUBERCULOSIS 

If recovery depended upon doing some big and 
spectacular task we would bend every energy to the 
contest; but, since success depends chiefly on renun- 
ciation and apparently doing nothing, many are con- 
founded and defeated by the very simplicity and 
tediousness of the task. They are like Naaman the 
Syrian, who, when Elisha told him to wash seven 
times in Jordan, said: "Are not the rivers of 
Damascus better than all the waters of Israel? 
Could I not have washed in them and been clean? 
Behold, I thought he would surely come out to me 
and stand and call on the name of the Lord his God, 
and wave his hand over the place and heal the 
leprosy." So he turned away in a rage, but his 
servants besought him saying, "If the prophet had 
bid thee do some great thing wouldest thou not have 
done it? How much rather then when he saith to 
thee, 'Wash and be clean.' " 

Worry is almost inevitable in the early reactions. 
It is no use telling a patient not to worry. He must 
achieve that state of mind by practice and discipline 
of his will-power, and not until he accomplishes it 
does he put himself in the fair way to recovery. The 
chief business now is to get well. All other consider- 
ations must stand aside if he is to put up his best 
fight. "Drag your thoughts away from your troubles 
. . . by the ear, by the heels, or any other way 
so you manage it." 



124 



TEMPERAMENTS AND TUBERCULOSIS 

The case of Alice Freeman Palmer is very in- 
structive. Her busy, successful and interesting life 
may be briefly summarized as follows: 

Born on a farm in an obscure border village. 

She learned to read at three; went to school at 
four; and at five looked after the three younger 
children in the family. 

She determined that she would secure the best 
education open to women in her day, "if it took fifty 
years to do it." She decided on the University of 
Michigan, and ended with the degrees of Ph.D., 
D.Litt., and LL.D. 

At twenty-two she was principal of a high school 
in Michigan; at twenty-four professor of history at 
Wellesley; at twenty-six president of Wellesley. At 
thirty-two she resigned the presidency to marry Pro- 
fessor Palmer of Harvard. Four years later at the 
urgent request of President Harper she served as 
Dean of Women in the University of Chicago for 
four years. 

At the last election of "Immortals" for the Hall 
of Fame at the University of New York she was the 
only woman elected. 

At the age of twenty-five she developed tuber- 
culosis. Dr. Bowditch of Boston told her that she 
must give up her work, and advised a trip to 
Southern France, warning her that unless great pre- 
cautions were observed she would have only a few 
more months to live. On her way home she con- 
sulted Dr. Willard Parker in New York and recorded 



125 



TUBERCULOSIS 

this note, "Dr. Parker tells me I can live if I have 
character and courage enough." She devoted herself 
entirely to the task of getting well, and after several 
months of rest cure at home made a good recovery, 
and never had any further trouble from tuberculosis. 
It was said of her, "She seldom hurried, never wor- 
ried, admitted no regrets for the past or anxieties for 
the future." 

We do not fully appreciate the value of health 
until we have lost it. The mental reaction which then 
ensues reveals the metal of the patient. Some poor 
souls thereupon pine away by dwelling on the mis- 
takes of the past and blaming others unduly for their 
share and influence in them, while the more philo- 
sophic and successful realize the folly of crying 
over "spilt milk" and at once set about to regain the 
lost treasure. The stern philosophy of Marcus 
Aurelius should prove helpful for some : 

"Look on every man who evinces pain or dissatis- 
faction at any event as on a level with the pig that 
is led out to sacrifice kicking and squealing. . . . 
The healthy mind will cheerfully accept all vicissi- 
tudes of fortune, while that which repines, 'O let me 
live,' or, 'Let all men praise my doings,' is on the level 
with the eye that will see nought but green, or the 
teeth which accept only the tenderest morsel, which 
is nought but a token of disease." 

I recall a woman who used to go about the sana- 
torium in her rustling silks and pour forth her woes 
and "beg" for sympathy as if she were the only person 



126 



TEMPERAMENTS AND TUBERCULOSIS 

that ever had her plans and pleasures interrupted by 
tuberculosis. In contrast there was another patient, 
extremely ill, and although he realized there was 
little hope yet his face was always bright, he had a 
word of encouragement for everyone, he radiated 
cheer and optimism, he was putting up the best fight 
he could. Everyone liked to visit him, because they 
felt that their storage batteries of courage and hope 
had been freshly charged when they left. 

Some are inclined to look upon the period of cure 
as a barren waste, as time irreparably lost. This 
will depend on the attitude and reaction of the 
patient. We can make it a period of profit, a period 
of reading, practice in self-control, and emerge a 
better citizen and neighbor, with keener appreciation 
of altruism, more self-reliant, and less dependent on 
others for the things that furnish the joy of living. 
Mark Twain offers a good example: 

"I have been sick a-bed, the first time in twenty- 
one years. How little confirmed invalids appreciate 
their advantages. I was able to read the English 
edition of the Greville Memoirs throughout without 
interruption, take my meals in bed, neglect all busi- 
ness without a pang, and smoke eighteen cigars a 
day." 

Professor Phelps said of Robert Louis Stevenson, 
a sufferer from tuberculosis for twenty-two years, 
"Prone in bed, when his attention was not diverted by 
a hemorrhage, he lived amid the pageantry of gor- 
geous day dreams, presented on the stage of his 

127 



TUBERCULOSIS 

brain." His joy in and love of life are expressed in 
the following aphorisms by him: "There is no duty 
we so much underrate as the duty of being happy"; 
"To travel hopefully is better than to arrive — the 
true success is in labor"; and, "Keep your fears to 
yourself, but share your courage with others." 

If our physical activities are limited our mental 
faculties have a better chance to flourish. As 
Cephalus said to Socrates, "As the pleasures respect- 
ing the body become insipid, the desire and pleasure 
of conversation increase," or, as Mark Twain put it, 
"The chief pleasure consists in the wagging of the 
gladsome jaw and flapping of the sympathetic ear." 
No wonder that many patients fall into boredom 
when separated from business and professional duties, 
because they have never thought of anything else, 
never read what others have thought and said about 
subjects that have interested brilliant minds. "Books 
are true levelers. They give to all who faithfully use 
them the society, the best and greatest of our race." 
Don't lock your mind in "solid ivory" when such 
questions as, "If a man die shall he live again?" 
knock for entrance. And I am inclined to believe 
that there are few who will not revise their philosophy 
of life and greatly improve their future conduct by 
such a period of trial, of study, and reflection. 

Everybody admires a cheerful loser. Our 
cherished dreams may be rudely broken up, and 
some by delay, some by folly make recovery im- 
possible, and some have to fight a losing battle from 

128 



" : KSJ 



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i::o:eii H: 
'i lt ~ T ~r:>zt :: ^115 frier iru 



not a : 

;-: .;■ 7 



TUBERCULOSIS 

and curdled me like cheese? Yea, he hath taken me 
by the neck and dashed me to pieces." But remember 
that, "After this Job lived an hundred and forty 
years, and had 14,000 sheep, 6,000 camels, 1,000 
yoke of oxen, and also seven sons and three 
daughters." And remember that Dr. Trudeau, after 
eight years of "chasing the cure," much of the time 
in bed, and after many apparently hopeless periods, 
did his greatest work. 

The remarkable case of John Burns, reported in 
the Journal of the Outdoor Life, is another most 
encouraging example. "The first seven years are the 
worst," said Mr. Burns, when asked for particulars 
about his case. 

The first year was spent literally in chasing the 
cure, from climate to climate and from doctor to 
sanatorium. He returned home and continued to get 
worse. After a few weeks he entered a local sana- 
torium and for six years lay on his back, unable even 
to attend to his toilet, and often having to be fed. 
During these six years he had five hundred haemor- 
rhages. 

"Smiling and uncomplaining, he kept on, pa- 
tiently following the doctor's advice, until now, after 
eight years, he has achieved what is termed 'full 
exercise' and is able to visit his home for a few days 
now and then. He has regained his normal weight 
and is a very healthy looking specimen of the genus 



130 



TEMPERAMENTS AND TUBERCULOSIS 

homo. There is no need for anyone to despair- 
think of John Burns, smile and get well." 
"It's the plugging away that will win you the day, 
So don't be a piker, old pard ! 
Just draw on your grit ; it's so easy to quit : 
It's the keeping your chin up that's hard." 



131 



*^ VI '^cPi 

DISTINGUISHED "T. B'S." 

"He alone is great 
Who, by a life heroic, conquers fate." 

— Bolton. 

"We are part of all we have met" — certainly no 
one has been introduced to tuberculosis and come 
off an unchanged man! The lessons of patience, 
courage, endurance, and hope turn out some truly 
noble and purged souls — souls attuned to the broadest 
and most sympathetic interests of mankind, and 
skilled in surmounting obstacles and overcoming 
handicaps. It is my purpose, and pleasure, to 
present a few of these characters for the encourage- 
ment and guidance of those who are apt to become a 
little scorched, instead of purified, in the fiery fur- 
nace. "If thou find aught in the life of man more 
excellent than a mind at peace with itself . . . , 
and at peace with destiny in the lot she assigns thee 
without thy choice . . . if," says Marcus 
Aurelius, "thou canst behold aught more excellent 
than this, turn to it with all thy soul and enjoy the 
highest to the utmost." 

Trwdeau. No one can qualify with higher marks 
for this chapter than the late Dr. Edward Livingston 
Trudeau (1848-1915). His experience with tuber- 
culosis began in 1865 when he nursed his brother 
through an acute and fatal attack of the disease. He 

133 



TUBERCULOSIS 

said, "It was my first great sorrow, — and I have never 
ceased to feel its influence. In after years it devel- 
oped in me an unquenchable sympathy for all tuber- 
culous patients — a sympathy which I hope has grown 
no less through a lifetime spent in trying to express 
it practically." Indeed, this was only the beginning 
of many great sorrows and trials which filled his cup 
of life. A few years later the same disease that had 
taken off his brother so quickly banished him from a 
most promising practice in New York to the Adiron- 
dack wilds. Three of his four children were taken 
from him; one in infancy, and two at the threshold 
of maturity — one with tuberculosis, and the other 
with pneumonia. His labors were frequently inter- 
rupted by relapses of tuberculosis, causing long 
periods of invalidism. Truly it can be said that "he 
was a man of sorrows, and acquainted with grief," 
but it never broke his indomitable spirit, and only 
deepened his sympathy and interest in his fellow 
sufferers, and strengthened his desire and determina- 
tion to serve them. 

His ancestors for several generations had been 
physicians, and he finally decided to study medicine, 
after drifting a while with his pleasure-loving com- 
panions. When he announced this decision to his 
club mates one of them offered to bet $500 that he 
would never graduate — and "no one was found to 
take the bet," says Dr. Trudeau. "This was the turn- 
ing point between an easy life of pleasure to one of 
work and responsibility. After this my evenings were 



134 



DISTINGUISHED "T. B'S." 

generally spent in the little hall bedroom with my 
anatomy instead of at the club with my boon com- 
panions." 

The teaching on tuberculosis at this time (1868) 
was very meagre. The tubercle bacillus had not been 
discovered, and tuberculosis was considered quite a 
hopeless disease. He tells of his experience in going 
down to New York from Saranac twelve years later 
in order to learn how to stain the tubercle bacillus 
which Koch had discovered in 1882. Even for sev- 
eral years after this "leading" physicians did not take 
much stock in germs, and the tubercle baccillus in 
particular. When he returned from this trip he found 
a Harvard student up there who had come to consult 
Dr. Loomis, a distinguished New York physician, 
who was on a hunting trip there at this time. In the 
meantime Dr. Trudeau examined the patient's sputum 
by his newly learned staining method, and found 
tubercle bacilli in it. This convinced him that the 
patient had tuberculosis in spite of the fact that the 
physical signs were slight and indefinite. When Dr. 
Loomis returned from his hunting trip he examined 
the patient and found no definite signs. Dr. Trudeau 
then told him about finding the bacilli in the sputum. 
But Dr. Loomis only smiled, and said that he didn't 
have much faith in germs anyway. He sent the 
patient on back to Harvard, and four months later he 
had a profuse haemorrhage which convinced Dr. 
Loomis that Dr. Trudeau was right. Dr. Loomis was 
afterwards one of Dr. Trudeau's strongest supporters. 

135 



TUBERCULOSIS 

Adirondack Cottage Sanatorium. When Dr. 
Trudeau discovered that he had tuberculosis his love 
of the woods and hunting drove him up to the Adiron- 
dack^ in spite of the protests of his friends and 
physicians. This life in the open and on the lake, 
where he spent the first five years of his illness, 
brought about an arrestment of his disease. He was 
then anxious that other patients should have the 
advantages of this open-air life and mountainous 
climate which had done so much for him. He was 
also favorably impressed with the sanatorium idea 
which Brehmer and Dettweiler had tried with such 
marked success in Germany, and decided to try it 
there at Saranac. Accordingly the Adirondack 
Cottage Sanatorium was started in 1884 with a very 
humble and meagre beginning. This was the pioneer 
institution in this country and he fully demonstrated 
and established its value in the treatment of tuber- 
culosis. His magnetic personality and unbounded 
sympathy and interest in his fellow sufferers attracted 
all classes of patients to these mountains, and now 
Saranac Lake is the most flourishing tuberculosis 
resort in the country. 

He determined that the poor, as well as the rich, 
should have the advantages of this sanatorium, and 
accordingly he gave his services to the institution en- 
tirely free, and charged for board, etc., far lass than 
the cost. This deficit, amounting to from $12,000 to 
$25,000 a year, he made up by begging subscriptions 
from his friends for a period of twenty years or more, 

136 



DISTINGUISHED "T. B'S." 

until in 1914 he had accumulated a productive en- 
dowment of over $600,000 for the sanatorium, in 
addition to the thoroughly equipped laboratory and 
adequate buildings and grounds — truly a great monu- 
ment to his ceaseless efforts and unflagging zeal ! 

In the early years of the sanatorium he devoted 
much time and work to research in his laboratory. 
A characteristic light is shed on his ideals in the fol- 
lowing statement about Robert Louis Stevenson, his 
distinguished patient: "He could not, as I could, 
look over and beyond these painful associations with 
which I lived in daily contact at the Sanatorium and 
the Laboratory, and see, as I did in my ideals, the 
glorious hope of future relief to humanity from sick- 
ness, suffering and death which lay in the study of 
disease at the bedside, and of infection and germs and 
sick animals in the Laboratory. This was the light 
which was so bright to me that I never noticed the 
smell of oil which overcame Stevenson." 

Dr. Trudeau lived to see the fruits of his labors 
at Saranac returning an hundred fold, and to receive 
the highest honors his colleagues could bestow upon 
him. He was the first President of the National 
Tuberculosis Association; President for the United 
States of the International Congress of Tuberculosis 
held in Washington in 1908; and President of the 
American Congress of Physicians in 1910. No one 
was ever held in higher esteem by his patients and 
colleagues. His autobiography, from which I take 
the above incidents, is a most encouraging and inter- 

137 



TUBERCULOSIS 

esting account of a busy, successful, and highly useful 
life handicapped by intermittently active tuberculosis 
for over forty years. 

Grancher. Professor Jacques Joseph Grancher 

( 1907), of Paris, taught and practiced among 

consumptives for twenty-five years, when he was 
taken off by an untimely death from tuberculosis. 
The French have been the pioneers in protecting 
children from tuberculous infection, and it was due 
to Dr. Grancher's clear perception and strong con- 
viction of the importance of this measure. He realized 
clearly that by far the most successful point at which 
to attack tuberculosis was in preventing the infection 
of children. He founded the Grancher Society whose 
purpose is to find homes for children of poor tuber- 
culous families among healthy peasant families, and 
thus remove these helpless children from the danger 
of infection from their ignorant, careless, and often 
helpless parents. These children are returned to 
their families at the age of thirteen if the parent has 
been cured, or has died, and the danger of infection 
removed. At the outbreak of the War this Society 
had 810 children under its supervision — only a small 
proportion of the thousands who need such help, to 
be sure, but it is pointing the way, and enlarging its 
activities as rapidly as it can obtain the co-operation 
and financial help required. At the time of his death 
he had planned and was working for the establish- 
ment of a "Sanatorium School" for children with 
latent tuberculosis, where they could have "double 

138 



DISTINGUISHED "T. B'S." 

rations" of fresh air, rest, good food; and a "half 
ration" of work. The need and usefulness of such 
institutions is now apparent to all — only the public 
interest and funds are lacking ! 

Dettweiler. Dr. Peter Dettweiler (1832-1904) 
was an army surgeon in 1870 when he developed 
tuberculosis and went to Dr. Brehmer's sanatorium 
at Goebersdorf, Germany (the first one established), 
where he recovered his health. He became Dr. 
Brehmer's assistant, and after 6 years established his 
own sanatorium at Falkenstein, which has been since 
its establishment "the Mecca for students of tuber- 
culosis all over the world." He was the first to recog- 
nize fully the importance of rest in the treatment of 
tuberculosis, and he introduced the "open-air rest cure 
on the reclining chair." He founded the first sana- 
torium for the consumptive poor, and it is to his 
initiative that Germany is indebted for her many 
institutions of this sort. Dr. Knopf said of him, "He 
was a charitable man, of unusual cordiality and kind- 
ness and strong personality — a friend, confessor, and 
physician to his patients." Dr. Baldwin said, "He 
began life as a tubercuouls invalid, and in conse- 
quence of ill health was considerably deprived of 
advantages ; but his delicate frame was animated by 
a determination and spirit that surely carries its 
lesson to those who look forward with doubts weigh- 
ing heavily upon them." 

Laennec. Rene Theophile Hyacinthe Laennec 
(1781-1826) was the most important and distin- 



139 



TUBERCULOSIS 

guished internist of the early French school, although 
an early victim of tuberculosis. His invention of the 
stethescope in 1819 opened up the possibility of 
accurate diagnosis of diseases of the heart and lungs, 
and at the same time made his name immortal. He 
was the first to recognize pneumothorax in a living 
patient, and described accurately its signs; the first 
to discover and describe the "anatomical tubercle"; 
the first to recognize bronchiectasis, haemorrhagic 
pleurisy, gangrene and emphysema of the lungs ; and 
he was the author of many terms which are now used 
in describing the physical signs in the chest. He was 
slight in stature, generous, tolerant, modest about his 
work, and stands out as one of the greatest clinicians 
of all ages. 

The medical profession contains many names that 
are worthy of a place in this chapter, but the size 
and scope of this little book permits only of the 
selection of a few. This is also true of the field of 
literature; and the following names selected from the 
various walks of life. 

Lanier. Sidney Lanier (1842-1881) was a son 
of the Old South, reared in a cultured and prosperous 
family according to the principles of chivalry and 
sociability which were in vogue in the South before 
the War. He graduated from Oglethorpe College, 
Milledgeville, Georgia, at the head of his class in 
July, 1860, and spent the rest of the summer on the 
estate of his grandfather at Montvale Springs in the 
mountains of East Tennessee. A glimpse into the 

140 



DISTINGUISHED "T. B'S." 

life of that time is expressed in the following extract 
from one of his letters: "I have up here in the 
mountains, — kinsfolk, men friends, women friends, 
books, music, wine, hunting, fishing, billiards, ten- 
pins, chess, eating, mosquitoless sleeping, mountain 
scenery, and a month of idleness." 

In the fall of the same year he returned to his 
Alma Mater as a tutor. He describes himself at this 
time as "a spare-built boy, of average height and 
under-weight, mostly addicted to hard study, long 
reveries, and exhausting smokes with a German pipe." 
The question uppermost in his mind at this time was 
that of a vocation. He had inherited the musical 
genius which was a marked trait in the Lanier 
family — Pepys mentions the "music-loving Laniers" 
in his diary. He had a decided bent and extra- 
ordinary talent for music and poetry, but they were 
not considered a "man's job" in his day and locality. 

His dreams of scholarship, music and poetry, 
however, were interrupted by the War from which 
he emerged broken in health and with the property 
of his family entirely swept away. 

At home, at college, in war, and in prison he 
entertained and charmed his friends and associates 
with his flute. A fellow prisoner of war said, "Many 
a stern eye moistened to hear him, many a homesick 
heart for a time forgot its captivity." He secured 
his release from prison through some gold which a 
friend smuggled into prison in his mouth. Extremely 
emaciated and weak he was rescued from death on 



141 



TUBERCULOSIS 

board the ship in which he was sailing for Fortress 
Monroe by an old friend who chanced to be present. 
She relates the incident as follows: "There in that 
horrible place dear Sidney Lanier lay wrapped in an 
old quilt his thin hands tightly clinched, his face 
drawn and pinched, his eyes fixed and staring. . . . 
At last he turned his eyes slowly about until he saw 
Lilla, and he murmured : 'Am I dead ? Is this Lilla ? 
Is this heaven?' . . . We gave him some hot 
soup and more brandy, and he lay quiet until after 
midnight. Then he asked for his flute and began to 
play. As he played the first few notes you should 
have heard the yell of joy that came up from the 
shivering wretches down below, who knew that their 
comrade was alive. And there we sat entranced about 
him, the colonel and his wife, Lilla and I, weeping 
at the tender music as the tones of new warmth and 
color and hope came like liquid melody from his 
magic flute." 

After the War he was a clerk and teacher in 
Alabama for a while, and then he studied and prac- 
ticed law with his father in Macon, Georgia, until 
1873. His passion for music and poetry finally pre- 
vailed and he went to Baltimore where he played the 
first flute in the Peabody Symphony Orchestra. In 
1879 he was made lecturer on English Literature at 
the Johns Hopkins University. His health during 
these years was very poor, and he made frequent trips 
to Florida and North Carolina in the effort to build 
up his waning health — spasmodic attempts at "chas- 

142 



DISTINGUISHED "T. B'S." 

ing the cure." In spite of his poor health he made 
most rapid progress and remarkable achievements for 
such a short time in the field of literature. He was a 
brilliant exponent of music in poetry as "The 
Marshes of Glynn" and "The Song of the Chatta- 
hooche" attest, and second only to Poe in the art of 
onomatopoeia. 

"His personality is one of the rarest and finest 
yet produced in America," says Professor Mims. 
And Dr. Gilman, President of Johns Hopkins, said 
of him, "He always preserved his sweetness of dis- 
position, his cheerfulness, his courtesy, his industry, 
his hope, his ambition. ..." 

Stevenson. Robert Louis Stevenson (1850-1894) 
was a peripatetic chaser of the cure, trying Davos, 
Bournmouth, Riviera, the Adirondacks, California, 
and finally Samoa, where he established his home in 
1890 — not a very wise course for a consumptive to 
pursue! "Where is Samoa?" asked a friend. "Go 
out of the Golden Gate and take the first turn to the 
left," replied Stevenson. 

His sensitive and idealistic nature made him far 
from a model patient. Dr. Trudeau said of him 
when he was a patient at Saranac: "His view was 
to ignore or avoid as much as possible unpleasant 
facts, and live in a beautiful, strenuous, and ideal 
world of fancy. He did not care to go to the sana- 
torium with me, or to see the laboratory, because to 
him these were unpleasant things." One day, how- 
ever, Dr. Trudeau got him into the laboratory from 



143 



TUBERCULOSIS 

which he escaped at the first opportunity with the 
words, "Trudeau, your light may be very bright to 
you, but to me it smells of oil like the Devil!" 

He was a native of Scotland; developed tuber- 
culosis at the age of twenty-one; four years later he 
was admitted to the bar, but his literary talents far 
outshone his legal lights, and he finally devoted him- 
self entirely to literature and "chasing the cure." 
Success first came with the publication of "Treasure 
Island," in 1882, followed by the masterpieces "Dr. 
Jekyll and Mr. Hyde," "The Master of Ballantrae," 
"Kidnapped," etc. 

Schiller. Johann Christoph Friedrich von Schiller 
(1759-1805) was Germany's greatest dramatic poet, 
if indeed, not her greatest litterateur among a field of 
formidable competitors. He desired to become a 
clergyman, but was "kindly kidnapped" by Duke 
Karl of Wuertemberg for his military academy in 
1773. However, in 1775, he began the study of 
medicine, and in 1780 was a regimental surgeon, but 
he found both his dress and duties galling. . In 1781, 
he published "Die Rauber," which was a vigorous 
protest against existing political conditions of which 
he had been a victim. He was thereupon forbidden 
to publish anything except medical treatises. How- 
ever, his literary genius was too great to be stifled by 
any such autocratic and bigoted order, and Germany 
was not deprived of her greatest dramas which he 
later produced, "Wallenstein's Tod" and "Wilhelm 



144 



DISTINGUISHED "T. B'S." 

Tell." They made a deep and enduring impression 
on the German mind. 

Democracy never had a more eloquent champion 
and her principles were never more clearly set forth 
than in his "History of the Revolt of the Nether- 
lands," in which he defends Queen Elizabeth of 
England for having taken Holland's part against the 
cruelties and oppression of Spain. Whether the 
tubercle bacilli had anything to do with purging his 
mind of modern Prussian bigotry and cruelty I won't 
say, but surely nothing was ever written that strikes 
the present ex-German Emperor more squarely in the 
face than the following quotations* from "The Revolt 
of the Netherlands." 



*Policy and humanity demand that a wrong perpetrated 
against a nation should be taken note of on all hands and 
punished. The interests of society at large clearly demand 
that the fundamental laws of states be not violated with im- 
punity; society must not remain passive in face of the 
deliberate provocation of a blind and outrageous tyrant. The 
common interests of mankind must direct the impulses of 
political bodies: European society has no other essential 
purpose. What? A whole nation should look on with in- 
difference when the blood of her neighbors is spilt by the 
absurd and barbaric whim of a despot? — all values revert 
back to the original conception of right to claim support and 
generous help for an oppressed people — the primeval and holy 
right of unhappy peoples." 

145 



TUBERCULOSIS 

After the publication of "Wilhelm Tell" in 1804 
he was invited to Berlin and "royally" welcomed. 
On his return from this trip, he was prostrated by 
illness and died in 1805 — having suffered from 
tuberculosis since 1790. 

Moliere. Moliere (1622-1673) holds the same 
place in French literature that Schiller does in Ger- 
man — the greatest dramatist of France, if not her 
greatest literary genius. Shakespeare should have 
had tuberculosis in order to make it unanimous — he 
is the exception which proves the rule that tuber- 
culosis produces the world's greatest dramatists ! 

The physician in the time of Moliere, to quote 
Dr. Garrison, "had become a sterile pedant and 
coxcomb, long-robed, big-wigged, square-bonneted, 
pompous, making a vain parade of his Latin, and 
attempting to overawe his patients by long tirades of 
technical drivel, which only concealed his ignorance 
of what he supposed to be their diseases." It is not 
strange then that the great dramatist had no use for 
the medical profession, whose ridiculous side drew 
forth his derision in five comedies aimed at the 
doctors. He seems also to have had a personal 
prejudice against them because they could not cure 
his malady (tuberculosis), and because he thought 
that they had killed his only son with their "eternal 
antimony." 

In "Le Malade Imaginaire" occurs the following 
choice bit of satire on the pompous ceremonies of 
medical graduation (which was accompanied and 

146 



DISTINGUISHED "T. B'S." 

followed by several days of feasting on the part of 
the examiners at the expense of the candidate) . The 
first doctor asks the question, "Why does opium 
produce sleep?" To which the candidate replies: 

Quia est in eo 

Virtus Dormitiva. 

(Because there is in it a sleep- 
giving quality.) 
which is greeted by the ogligato chorus : 

Bene, bene, bene, bene respondere 

Dignus, dignus est intrare 

In nostra docto corpore! 

(Well, well, well, well answered, 

worthy he is worthy to enter 

into our learned body ! ) 

He is then plied with various questions, and his 

answer to each one is greeted by the chorus, "Bene, 

bene, etc." 

Moliere met his death on the stage while he was 
playing the role of the hypochondriac invalid in the 
above comedy. During the play he had a severe 
coughing spell which brought on a profuse haemor- 
rhage from which he died in half an hour. 

Artemus Ward. Charles Farrar Browne (1834- 
1867) gained the pen name of "Artemus Ward" by 
publishing in the Cleveland Plain Dealer the very 
humorous and atrociously spelled "sayings of 
Artemus Ward." In 1860 he moved to New York 
and took a position on the editorial staff of Vanity 
Fair. However, he soon entered upon the lecture 



147 



TUBERCULOSIS 

platform as a humorous lecturer. He developed 
tuberculosis in 1864. In 1866 he undertook a lecture 
tour in England against the advice of his physicians, 
and lectured almost to the time of his death in 1867. 
Just before his death his friend Robertson tried to get 
him to take a nauseous draught, and when he refused 
saying that he could not take the nasty stuff, Robert- 
son urged him saying, "Come, now, you know I 
would do anything for you," to which Ward replied, 
"Then you take it." 

Colonel Henry Waterson, who saw him fre- 
quently at the time Artemus Ward was lecturing in 
London, says of him: "I find from notes jotted 
down at the time that the last I saw of him was the 
evening of the 21st of December, 1866. He had dined 
with my wife and myself, and, accompanied by 
Arthur Sketchley, who had dropped in after dinner, 
he bade good-bye and went for his nightly grind, as 
he called it. . . . He was too feeble to walk 
alone. . . . His surgeon had forbidden the use 
of wine or liquor of any sort. Instead he drank 
quantities of water, eating little, and taking no exer- 
cise at all. Nevertheless, he stuck to his lecture and 
contrived to keep up appearances before the crowds 
that flocked to hear him, and even in London his 
critical state of health was not suspected. 

"His was one of those receptive natures which 
enjoy whatever is bright and sunny. . . . He 
poured out the wine of life in limpid stream and was 
possessed of rare individuality*. It may be fairly 



148 



DISTINGUISHED "T. B'S." 

said that he did much to give permanency and 
respectability to the style of literature of which he 
was at once a brilliant illustrator and illustration." 

Wright. Harold Bell Wright, painter, preacher, 
author, "t. b.," is said to be the only novelist who 
ever made a million dollars from his books. "It is 
an ill wind that blows nobody good," and no doubt 
the tubercle bacilli are largely responsible for his 
"windfall" when they blew him from the pulpit to 
the press. 

Wesley. John Wesley, founder of the Methodist 
Church, and probably the most incessant worker that 
has ever inhabited our globe, is another most encour- 
aging example. At the age of fifty he suffered an 
acute and severe attack of tuberculosis. He said in 
his diary, "I caught cold and developed pain in my 
left chest, a violent cough, and a slow fever." And, 
he adds, "Dr. Fothergill told me, 'If anything does 
thee good it must be the country air, with rest, asses' 
milk, and riding daily.' " (Excellent advice, with the 
exception of the daily rides, according to present 
knowledge. This was in 1753.) His brother Charles, 
the great hymn writer, visited him at this time and 
wrote, "He is still in imminent danger, being far 
gone, and very suddenly, in a consumption." It is 
evident that Wesley did not expect to survive this 
severe illness, as he wrote his own very interesting 
epitaph, as follows: 



149 



TUBERCULOSIS 

Here lieth the Body 
of 
John Wesley, 
A Brand plucked from the burning; 
Who died of a Consumption in the Fifty-first Year 
of his Age, 
not leaving, after his Debts are paid, 
Ten Pounds behind him: 
Praying, 
God be merciful to me, an unprofitable servant ! 
His expectations, however, were not realized. He 
made a good recovery and obtained a permanent ar- 
restment of his disease, and lived to the ripe old age 
of eighty-eight years. It is estimated that during 
his fifty years of itinerant ministry he traveled 250,- 
000 miles, preached over 40,000 sermons, and wrote 
more than two hundred books and pamphlets. 

Mrs. "A" desires that her name be withheld, but 
her example is eminently worthy of record in this 
chapter, and I give it that others may follow suit. 
"Man's inhumanity to man 
Makes countless thousands mourn.*' 
But Mrs. "A's" humanity and thoughtful kindness 
during her stay in the New Mexico Cottage Sana- 
torium made many of her fellow patients rejoice. 
She not only contributed many valuable books to the 
library 7 , but carried them around to different patients 
who were not able to go for them, and thus aroused 
the interest of many in good literature. She sent her 
victrola with a large selection of the best records to 



150 



DISTINGUISHED "T. B'S." 

various patients to be kept for a few days, and only 
at rare intervals would it get back to her cottage, 
when new records would be tried and added to the 
collection, and then it would go out for another round 
of cheer. She sent flowers to the sickest ones, and was 
a source of comfort and encouragement to all. In- 
deed, more than one patient shed tears over her 
departure — a testimony of gratitude beyond the pale 
of words — because they felt her genuine interest in 
them, and because she truly fulfilled the ideal in the 
lines : 

"Who gives himself with his alms feeds three, — 
Himself, his hungering neighbor and Me." 
If the reader desires further encouragement from 
the lives of distinguished "t. b's," he can find it in 
John Paul Jones, Andrew Jackson, Bichat, Keats, 
Stern, Heine, Thoreau, Spinoza, Raphael, Chopin, 
Bastien le Page, John Sterling, Henry Timrod, Alice 
Freeman Palmer, Anton Lang, Kerensky, Rodger 
Babson, and many others who achieved fame and use- 
fulness in spite of tuberculosis. 



151 



APPENDIX 



WEIGHT ACCORDING TO AGE AND HEIGHT 















MEN 








Inches 

Age 

15-19... 


62 
116 


63 
120 


64 
124 


65 
128 


66 
132 


67 
136 


68 
140 


69 
144 


70 

148 


20-24__ 


123 


127 


131 


135 


139 


142 


146 


150 


154 


25-29__ 


126 


130 


134 


138 


142 


146 


150 


154 


158 


30-34„ 


129 


133 


137 


141 


145 


149 


154 


158 


163 


35-39— 


132 


136 


140 


144 


148 


152 


157 


162 


167 


40-44__ 


134 


138 


142 


146 


150 


154 


159 


164 


169 


45-49__ 


136 


140 


144 


148 


152 


156 


161 


166 


171 


50-54__ 


137 


141 


145 


149 


153 


157 


162 


167 


172 



71 



73 74 



153 158 163 168 

158 163 168 173 

163 169 175 181 

168 174 180 186 

172 178 184 190 

175 181 187 193 

177 183 190 196 

178 184 191 198 



Inches 

Age 
15-19.. 
20-24. _ 
25-29._ 
30-34. _ 
35-39. _ 
40-44.. 
45-49._ 
50-54_. 



WO^IEN 

60 61 62 63 64 65 66 67 6S 69 



71 72 



109 113 117 120 123 126 

112 116 120 123 126 129 

114 118 122 125 129 132 

117 121 125 128 132 136 



130 134 138 141 145 150 155 

133 137 141 145 149 153 158 

136 140 144 148 152 155 159 

140 144 148 152 155 158 160 



121 125 129 132 136 140 144 148 152 156 159 162 165 

127 129 133 136 139 143 147 151 155 159 162 166 170 

128 132 136 139 142 146 151 155 159 163 166 170 174 
130 134 138 141 144 148 152 157 162 166 170 174 178 



Vitamins are constituents of our 
food that are essential to 
health. 

It is not necessary to buy 
''patent medicine" vitamins 
in tablet form. 

A diet containing all the vita- 
mins necessary can easily be 
selected from our every-day 
foods. 

Three vitamins are known at 
present: A, B, and C. 

—Ed. 



A deficiency of 
may result 



the diet 
symptoms of 



rickets, an eye disease. 

A deficiency of "B" may result 
in loss of appetite and sym- 
ptoms of the disease Beriber. 

A deficiency in "C may result 
in symptoms of scurvy- 

A deficiency of any of the vita- 
mins in the diet of children 
will result in impaired growth. 

Poster by Am. Med. Assoc. 



152 



APPENDIX 



VITAMINS IN FOODS 



Bread- 
White (Water) ___. 

White (Milk) 

W. Wheat (Water) 
W. Wheat (Milk). 

Barley (Whole) 

Corn, Yellow 

Oats 

Beef Fat 

Mutton Fat 

Pig Kidney Fat 

Oleomargarine 

Liver 

Kidney 

Brains 

Sweetbreads 

Fish, Lean f $ 

Fish, Fat 

Fish, Roe 

Milk, Fresh f 

Milk, Condensed f 

Milk, Dried (Whole) t 
Milk, Skimmed __. 

Buttermilk 

Cream 

Cheese ] * 

Cottage Cheese __ 



Almonds 

Coconut 

Hickory Nuts 

Peanuts 

Pecans 

Walnuts 

Tomatoes (Raw or 
Canned) 



Beans, Kidney 

Beans, Navy 

Beans, String (Fresh) 
Cabbage, Fresh, Raw 

Cabbage, Cooked 

Carrots, Fresh, Raw . 

Carrots, Cooked 

Cauliflower 

Celery 

Cucumber 

Dandelion Greens — 

Eggplant, Dried 

Lettuce 

Onions 

Parsnip 

Peas 

Potatoes (15 min.) _. 

Potatoes (1 hr.) 

Potatoes (Baked) _— 
5weet Potatoes 
Radish 



T^" 



BTC 

t § 

t 



t? 



Spinach, Fresh 

Spinach, Dried 

Squash, Hubbard _, 

Turnips 

Apples 

Bananas 

Grape Juice 

Grapefruit 1 § 

Lemon Juice 1 § 

Orange Juice | * 

Prunes I § 

Raspberries (Fresh 
or Canned) 



J? I* 



J § 
*? 



» t? 

t § 

** § 



•I t 

.. . t 

t 



I, I 



§ 1 § I t 



**Good source of the Vitamin. 
•Contains the Vitamin. 
JNo appreciable amount of the Vitamin. 
fExcellent source of the Vitamin. 

PDoubt as to presence or relative amount. 
§Evidence lacking or insufficient. 
^Variable. 

— Ed. Poster by Am. Med. Assoc. 



153 



APPENDIX 



COMMON FOODS CLASSIFIED* 





Poor in 
Fat 


Rich in 
Fat 


Very Rich in 
Fat 


Very high in 
Protein 


White of Eggs 
Cod Fish 
Lean Beef 
Chicken 
Veal 






High in 
Protein 


Shell-fish 
Skim Milk 
Lentils 
Peas 
Beans 


Most Fish 
Most Meats 
Most Fowl 
Whole Egg 
Cheese 




Moderate or 
Deficient in 
Protein 


Most 

Vegetables 
Bread 
Potatoes 
Fruits 
Sugar 


Peanuts 
Milk 

Cream Soups 
Most Pies 
Doughnuts 


Fat Meats 
Yolk of Eggs 
Most Nuts 
Cream 
Butter 



*This table and the following tables on food values are from 
"How to Live," by Drs. Fisher and Fisk, 15th edition, published by 
Funk and Wagnalls. 



154 



APPENDIX 

TABLE OF FOOD VALUES*" : 



NAME OF FOOD 



Vegetables 



Artichokes, as purchased, average, canned... 
* Asparagus, as purchased, average, canned. _. 
*Asparagus, as purchased, average, cooked. _. 

*Beans, baked, canned 

*Beans, Lima, canned 

*Beans, string, cooked 

*Beets, edible portion, cooked 

*Cabbage, edible portion 

Carrots, edible portion, average, fresh 

Carrots, cooked 

*Cauliflower, as purchased, average 

*Celery, edible portion, average 

Corn, sweet, cooked 

*Cucumbers, edible portion, average 

*Egg plant, edible portion, average 

Lentils, cooked 

*Lettuce, edible portion, average 

*Mushrooms, as purchased, average 

*Onions, fresh, edible portion, average 

*Onions, cooked 

*Parsnips, edible portion, average 

Parsnips, cooked . 

*Peas, green, canned 

*Peas, green, cooked 

Potatoes, baked 

^Potatoes, boiled 

*Potatoes, mashed (creamed) 

*Potatoes, steamed 

*Potatoes, chips 

*Potatoes, sweet, cooked 

*Pumpkins, edible portion, average 

Radishes, as purchased 

Rhubarb, edible portion, average 

*Spinach, cooked, as purchased i 

*Squash, edible portion, average 

*Succotash, canned, as purchased, average. 

*Tomatoes, fresh, as purchased, average 

*Tomatoes, canned 

Turnips, edible portion, average 

Vegetable oysters 

*Apples, as purchased 

Apples, baked 

Apples, sauce 

*Apricots, edible portion, average 

Apricots, cooked 



19. 
7.19 
2.66 
4.44 

16.66 
8.7 

17. 
7.6 
5.81 

11. 

19. 
3.5 

20. 

12. 
3.15 

18. 
7.6 
7.1 
8.4 
5.3 
5.74 
6.3 
3. 

3.05 
3.62 
3.14 
3.57 
.6 
1.7 

13. 

17. 

15. 
6.1 
7.4 
3.5 

15. 

15.2 
8.7 
9.62 
7.3 
3.3 
3.9 
5.92 
4.61 



5 
40 

7 
34 

3 
27 

1 

1 
25 

1 | 88 
63 I 33 

9 85 

4 | 81 

3 | 79 
27 | 63 
15 | 66 | 19 



73 
72 
61 
61 

82 
48 

83 
56 
72 
50 
88 
88 
65 



78 
9 [ 76 
16 I 69 
7 72 

4 83 
51 I 39 

7 | 90 

5 93 
5 93 
92 
I 94 



155 



APPENDIX 



TABLE OF FOOD VALUES— Continued 



*Bananas, yellow, edible portion, average.. 
•Blackberries, as purchased, average 

Blueberries 

•Blueberries, canned, as purchased 

Cantaloupe 

•Cherries, edible portion, average 

•Cranberries, as purchased, average 

•Grapes, as purchased, average 

Grapefruit 

Grape juice 

Gooseberries 

•Lemons 

Lemon juice 

Nectarines 

Olives, ripe 

•Oranges, as purchased, average 

Oranges, juice 

•Peaches, as purchased, average 

Peaches, sauce 

Peaches, juice 

•Pears 

Pears, sauce 

•Pineapples, edible portion, average 

Raspberries, black 

Raspberries, red 

•Strawberries, as purchased, average 

•Watermelon, as purchased, average 



7.5 
4.8 
7.57 
4.2 
9.2 
7.57 
8.77 
5.18 
1.31 
9.4 
6.62 
10. 
4.78 
4.80 
5.40 
3.98 
8. 

5.18 
6.29 



Fruits (Dried) 



•Apples, as purchased, average 

Apricots, as purchased, average.. 
•Dates, edible portion, average... 

•Dates, as purchased 

•Figs, edible portion, average 

•Prunes, edible portion, average... 

•Prunes, as purchased 

•Raisins, edible portion, average... 
•Raisins, as purchased 



1.2 

1.24 



1.14 
1.35 



Cooked Meats 



fBeef, round, boiled (fat), 1099$ 

tBeef, round, boiled (lean), 1206$ 

fBeef, round, boiled (med.), 1188$ 

fBeef, 5th right rib, roasted, 1538$ 

tBeef, 5th right rib, roasted, 1616$ 

tBeef, 5th right rib, roasted, 1615$ 

tBeef, ribs, boiled, 1169$ 

tBeef, ribs, boiled, 1170$ 

•Calves foot jelly, as purchased 

•Chicken, as purchased, canned 

•Lamb chops, boiled, edible portion, average.. 

•Lamb, leg, roast 

tMutton, leg, boiled, 1184$ 

tPork, ham, boiled (fat), 1174$ 



1.3 


40 


60 


2.2 


90 


10 


1.6 


60 


40 


.65 


12 


88 


1.2 


25 


75 


.88 


18 


82 


1.1 


27 


73 


.87 


21 


79 


4. 


19 


00 


.96 


23 


77 


.96 


24 


76 


1.8 


40 


60 


1.2 


35 


65 


.73 


14 


86 



156 



APPENDIX 



TABLE OF FOOD VALUES— Continued 



tPork, ham, boiled, 1192$ 

tPork, ham, roasted (fat), 1484$ 

tPork, ham, roasted (lean), 1S11J.. 

"Turkey, as purchased, canned 

tVeal, leg, boiled, 1182$ 



Cakes, Pastry, Pudding and Desserts 



*Cake, chocolate layer, as purchased.. 

*Cake, gingerbread, as purchased 

*Cake, sponge, as purchased 

Custard, saramel 

Custard, milk 

Custard, tapioca 

"Dougnuts, as purchased 

*Lady fingers, as purchased 

"Macaroons, as purchased 

Pie, apple, as purchased 

*Pie, cream, as purchased 

"Pie, custard, as purchased 

"Pie, lemon, as purchased 

"Pie, mince, as purchased 

*Pie, squash, as purchased 

Pudding, apple sago 

Pudding, brown betty 

Pudding, cream rice 

Pudding, Indian meal 

Pudding, apple tapioca 

Tapioca, cooked 



.96 
.89 
2.51 
4.29 
2.45 
.8 
.95 
.82 
1.3 



Cereals 



*Bread, brown, as purchased, average 

*Bread, corn (johnnycake), as purchased, avg. 
"Bread, white, home made, as purchased 

Corn flakes, toasted 

"Corn meal, granular, average 

*Corn meal, unbolted, edible portion, average 

"Crackers, graham, as purchased 

"Crackers, oatmeal, as purchased 

"Hominy, cooked 

"Macaroni, average 

"Macaroni, average, cooked 

"Oatmeal, average, boiled 

'Popcorn, average 

"Rice, uncooked 

"Rice, boiled, average 

"Rice, flakes 

"Rolls, Vienna, as purchased, average j 

"Shredded wheat I 

"Spaghetti, average 1 

"Wheat flour, entire wheat average 

"Wheat flour, graham, average 1 

"Wheat flour, patent roller process, family | 
and straight grade spring wheat average 1 

"Zwieback I 



1.5 

1.3 

1.3 
.97 
.96 
.92 
.82 
.81 

4.2 
.96 

3.85 

5.6 



.94 | 
.97 

.96 
.96 



87 
83 
71 
75 
78 
90 
89 
91 

12 | 7 | 81 

13 | 4.5| 82.5 
12 j 1 j 87 
15 5 80 
15 5 I 80 



.97 | 12 | 3 | 85 
.81 | 9 | 21 | 70 



157 



APPENDIX 

TABLE OF FOOD VALUES— Continued 



Dairy Products 



*Butter, as purchased 

*Buttermilk, as purchased 

"■Cheese, American, pale, as purchased 

*Cheese, cottage, as purchased 

*Cheese, full cream, as purchased 

♦Cheese, Neufchatel, as purchased , 

♦Cheese, Swiss, as purchased 

*Cheese, pineapple, as purchased 

♦Cream 

*Kumyss J__ 

♦Milk, condensed, sweetened, as purchased 

♦Milk, condensed, unsweetened (evap. cream), 

as purchased 

*Milk, skimmed, as purchased 

*Milk, whole, as purchased 

♦Whey, as purchased 



.44 


.5 


99.5 


1 9.7 


34 


12 


.77 


25 


73 


3.12 


76 


8 


] .82 


as 


73 


1.05 


22 


76 


.8 


25 


74 


.72 


25 


73 


1.7 


5 


86 


6.7 


21 


37 


1.06 


10 


23 


2.05 


24 


50 


9.4 


37 


7 


4.9 


19 


52 


13. 


15 


10 



42 

67 

26 
56 
29 

75 



Sweets and Pickles 



*Catsup, tomato, as purchased, average.. 

♦Honey, as purchased 

♦Marmalade (orange peel) 

*Molasses, cane 

*01ives, green, edible portion 

*01ives, ripe, edible portion 

♦Pickles, mixed, as purchased 

*Sugar, granulated 

♦Sugar, maple 

♦Sirup, maple 



16. I 10 I 3 I 87 

| 1.05 I 1 99 

| 1. | .5| 2.5| 97 

.5| | 99.5 



1.2 

1.1 
1.3 
14.6 



Nuts 



♦Almonds, edible portion, average 

♦Beechnuts 

*Brazil nuts, edible portion 

♦Butternuts „ 

♦Coconuts 

♦Chestnuts, fresh, edible portion, average 

♦Filberts, edible portion, average 

♦Hickory nuts 

♦Peanuts, edible portion, average 

♦Pecans, polished, edible portion 

♦Pine nuts (pignolias), edible portion 

♦Walnuts, California, edible portion 



.53 


13 


77 


.52 


13 


79 


.49 


10 


86 


.50 


16 


82 


.57 


4 


77 


1.4 


10 


20 


.48 


9 


84 


.47 


9 


85 


.62 


20 


63 


.46 


6 


87 


.56 


22 


74 


.48 


10 


83 



Miscellaneous 



♦Eggs, hen's, boiled 2.1 32 6S 00 

♦Eggs, hen's, whites 6.4 100 00 

♦Eggs, hen's, yolks .94 17 83 00 

♦Omelet 3.3 34 60 6 

♦Soup, beef, as purchased, average 13. 69 14 17 

♦Soup, bean, as purchased, average 5.4 20 20 60 

♦Soup, cream of celery, as purchased, average.. 6.3 16 47 37 

♦Consomme, as purchased 29. 85 00 15 

♦Clam chowder, as purchased 8.25 17 18 65 

♦♦Abstracted from A Graphic Method of Practical Dietetics, Irving 
Fisher, Journal of A. M. A., Vol. xlviii, pp. 1316-1324. 

♦Chemical Composition of American Food Materials. Atwater and 
Bryant. U. S. Department of Agriculture Bulletin, No. 28, office of 
Experiment Stations. 

tExperiments on Losses in Cooking Meats (1900-03). Grindley, 
U. S. Department of Agriculture Bulletin, No. 141, office of Experi- 
ment Stations. 

JLaboratory number of specimen, as per Experiments on Losses 
in Cooking Meat. 



APPENDIX 



ESTIMATED WHOLESALE COST OF THE UNCOOKED 

INGREDIENTS OF 2500 CALORIES CONTAINED IN 

STANDARD FOODS ARRANGED ACCORDING 

TO THEIR INCREASING COST 

Apple tapioca pudding _- $04 

Rice, boiled (side order) -04 

Bath buns .06 

Pie, apple -07 

Pie, rhubarb 08 

Apple, baked .09 

Pie, strawberry .09 

Cocoa 09 

Crullers .10 

*Fish cakes with tomato sauce .13 

Muffins, corn .13 

*Lamb croquette and mashed potatoes .14 

*Beans, Boston baked .15 

*Beef, corned .15 

Pie, lemon .15 

Chicken wings on toast • i .16 

Napoleon .16 

*Salad, potato .16 

Toast, buttered .16 

Cream roll .17 

*Beef, creamed, chipped, on toast .18 

Cakes, butter ___ .19 

*Roast, Vienna, and spaghetti and potatoes .19 

Pudding, tapioca, creamed .20 

Sandwich, oyster .20 

*Veal cutlet, breaded and tomato sauce .20 

*Beef, corned, hash browned in pan .21 

*Liver and bacon .21 

*Roast, Vienna, with French fried potatoes .21 

*Stew, lamb .21 

*Beans, New York, baked .22 

Cakes, buckwheat, with maple cane sirup .22 

Coffee, cup of (contained cream and sugar) .22 

Pudding, bread, with vanilla sauce .24 

*Beef, corned, hashed, steamed .25 

Oatmeal, fresh cooked, with cream .25 

*Stew, beef .25 

Pie, oyster .26 

Potatoes, French fried, extra order .26 

*Sandwich, ham .26 

*Beef, creamed, chipped .27 

*Sandwich, corned beef i .27 

*Beef, corned, hashed, steamed, with poached" egg .28 

*Mackerel, broiled salt, with mashed potatoes .28 

Milk .29 

Pudding, rice, cold ""__"" .29 

*Rice, hot, with poached egg .29 

Soup, bean, with croutons " .29 

*Sandwich, minced chicken .30 

Cornstarch, chocolate, with cream ™ '31 

Ice cream, strawberry jl 

*Omelet, ham '_'_'_'_ j? 

Sandwich, cream cheese walnut ~~~~ZII .32 

159 



APPENDIX 



*Omelet, plain -33 

Cornstarch, vanilla, with cream .34 

•Omelet, onion .34 

*Oyster fiy, small .34 

•Sandwich, fried egg .35 

Sausage, country .35 

*Chicken croquette and French fried potatoes .36 

*Eggs, creamed, on tcast .36 

*Omelet, parsley .37 

*Omelet, Spanish, with French fried potatoes .37 

•Sandwich, tomato .39 

•Eggs, scrambled (2) .40 

•Lamb chops (2) .40 

Sandwich, club .40 

•Salad, tuna fish .41 

•Sandwich, chicken, sliced .43 

•Steak, tenderloin .43 

•Ffam, fried .44 

•Sandwich, roast beef, hot .44 

Strawberries with cream .44 

Toast, milk .45 

•Eggs, boiled (2) ! .47 

•Omelet, chicken .47 

•Sandwich, minced chicken with lettuce .49 

•Eggs, poached on toast (2) .59 

•Shad, baked, and dressing . .61 



•These orders contained bread and butter, which are figured in 
the food values. Of the orders containing bread the fractional part 
of the nutritional energy of the order from this source averaged 43.7 
per cent of the total. 



160 



APPENDIX 

STANDARDS FOR THE DIAGNOSIS, CLASSIFICATION AND 
S T TilATMENT OF TUBERCULOSIS IN CHILDREN 
AND ADULTS 

(Prepared by The Diagnostic Standards Committee of the 
National Tuberculosis Association) 

Definitions 

(1) Loss of Weight. By loss of weight should be understood an 
unexplainable loss of at least 5 per cent below normal limits ,f ox ^that 
particular individual, over a period of four months, or failure to 
gain weight in four months by child. . ■ 

(2) Low o/ S*ren#fc. By loss of strength m its pathological sense 
is meant ease of tire and lack of staying power which are unusual 
for that individual and which cannot be satisfactorily explained. 

(3) Fever In young children rectal temperatures alone are de- 
pendable. To constitute fever in its pathological sense in childhood 
there must be a more or less constant elevation of temperature over 
100 degrees, taken at various times during the day and lasting over a 
period of at least one week. In older children temperature rules for 
adults apply. For adults 99.4 for one week constitutes fever. 

(4) Elevation of Pulse. No definite standards can be laid down 
as to what constitutes elevation of pulse, as this varies according to 
the age. Observation should be over a longer period, and a wider 
latitude allowed, than in adults, before attaching significance to this 
as a symptom in childhood. 854_ in men and 90_J_ in women should 
be considered abnormal. 

(5) Hemorrhage. As in adults, any amount of blood, with or 
without sputum, requires medical investigation as to its source. 
This is a rare symptom in childhood. 

(6) Family History. An occasional case of tuberculosis in the 
patient's uncles, aunts, cousins, etc., should not be considered of 
importance, unless there has been intimate exposure and personal 
contact with such a case. It is an important fact, however, when 
the patient's immediate relatives, as mother, father, brother, sister, 
nurses, nursemaids, attendants, etc., have been tuberculous, and 
especially so when there has been prolonged and intimate contact. 

(7) Exposure. Exposure to tuberculosis in childhood, no matter 
how slight, from human sources or from milk and milk products, is 
of very great importance. Prolonged exposure, especially under un- 
hygienic habits or surroundings, is of still greater importance. This 
question should be gone into with the utmost care. It is of less 
importance in adults, but may be a factor. 

(8) Cough. No cough is characteristic of tuberculosis. Persistent 
cough for six weeks requires investigation. Tuberculosis can and 
often does exist without any cough whatsoever. In certain cases of 
bronchial gland tuberculosis there may be a brassy, strident, 
paroxysmal cough resembling that of pertussis. 

(9) Sputum. Sputum, if present, should be examined. It is com- 
paratively rare in tuberculosis in childhood. 

(10) Hoarseness. Any huskiness or persistent hoarseness requires 
investigation. This is likewise rare in childhood. 

(11) Rales. Rales are not to be regarded as essential in diagnosis 
and are not in themselves alone evidence of tuberculosis. In fact by 
the time rales are found in tuberculosis in childhood the disease is 
usually advanced and the diagnosis only too evident. 

(12) Dulness. Only very light percussion should be used. Dulness 
is not to be looked for at the apices as in adults, but over both sides 

161 



APPENDIX 



of the sternum (parasternal dulness), and between the scapulae 
(interscapular dulness). 

(13) Altered Voice and Breath Sounds. Pure bronchial breathing 
and egophony are comparatively rare in tuberculosis in childhood. 
Harsh, prolonged, high pitched expiration and an intense whispered 
voice are often present. The whispered voice and not the spoken 
voice should be used. 

(14) D'Espine's Sign. Intense whispered voice heard below the 
third dorsal vertebra is considered by many as abnormal and 
indicates the presence of enlarged bronchial glands. Such glands 
are not necessarily tuberculous, however. 

The Diagnosis of Thoracic (Pulmonary, Bronchial Gland, Etc.) 
Tuberculosis in Childhood 

(1) Given a definite history of exposure, either from bovine or 
human sources, any symptoms, constitutional or local, require the 
most careful investigation, although they may not necessarily be due 
to tuberculosis. 

(2) Constitutional signs and symptoms of disease, such as loss of 
weight and strength, fever, etc., are of more importance than signs 
and symptoms relating to the chest. 

(3) Other causes for constitutional signs and symptoms, such as 
diseased tonsils or adenoids, carious teeth, improper feeding, rickets, 
etc., should be investigated before these signs and symptoms are 
attributed to tuberculosis. 

(4) The presence of tuberculosis elsewhere in the body, such as 
glands, bones, joints, etc., is not necessarily indicative of tuberculosis 
in the chest, nor is it true that these forms of tuberculosis convey 
immunity against pulmonary- disease. 

(5) There may be extensive signs in the lungs, such as dulness, 
rales, altered voice and breath sounds, without these being due to 
tuberculosis. On the other hand, active tuberculosis may be present 
without definite signs and symptoms in the lungs. 

(6) Tuberculin tests. The Von Pirquet skin test is the best to 
use. When this test, properly applied, has been repeatedly negative 
on three trials, except during or after an attack of measles, or in the 
presence of far advanced tuberculous disease, tuberculosis may be 
ruled out. A positive skin test in children under five years of age 
may be indicative of tuberculous disease, and points to the necessity 
for further observation. The diagnostic value of a postive tuberculin 
test becomes progressively less important, as significant of active 
disease rather than infection, in the years from five to fourteen. 

(7) A definite history of exposure, with a positive tuberculin 
reaction, accompanied by constitutional signs and symptoms, estab- 
lishes a diagnosis of tuberculosis, even if the signs in the chest are 
vague, indefinite or absent. A similar history of exposure, even with 
a positive tuberculin reaction, but without constitutional signs and 
symptoms and without definite signs in the chest, does not justify 
a diagnosis of tuberculous disease, but merely of tuberculous in- 
fection, except in very young children. 

(8) The X-ray may give valuable confirmatory evidence. A 
definite diagnosis of tuberculosis is not justified on X-ray examina- 
tion alone. In every case the interpretation of the X-ray plate should 
be made by one qualified to decide in such matters. 

(9) In all cases in which there is doubt, it is better to make a 
provisional diagnosis of tuberculosis and to give the child the benefit 
of hygienic measures and prolonged observation, although this need 

162 



APPENDIX 



not necessarily mean that the child be sent to a sanatorium or 
hospital or be definitely stamped as a consumptive. 

(10) Finally, a correct diagnosis can be reached only by means 
of common sense and a careful consideration of a multiplicity of 
minor signs and symptoms, local and constitutional. 

The Diagnosis of Pulmonary Tuberculosis in Adults with 
Negative Sputum 

(1) When constitutional signs and symptoms and definite past 
history are absent or nearly so, there should be demanded definite 
signs in the lungs, including persistent rales at one or both apices. 
By "persistent" it is meant that the rales must be present after cough 
at two or more examinations, the patient having been under obser- 
vation at least one month. 

(2) In the presence of constitutional signs and symptoms such as 
loss of weight and strength, etc., as defined above, there should be 
demanded some abnormality in the lungs, but not necessarily rales. 

(3) Usually a process at the apices should be considered tuber- 
culous and a process at the base to be non-tuberculous until the 
contrary is proved, excepting when a clear history of pleurisy is 
present. 

(4) A hemorrhage as defined above is evidence of active pulmonary 
tuberculosis until the contrary is proved. 

(5) One should consider a typical pleurisy with effusion as pre- 
sumptive evidence of tuberculosis. One should also consider a dry 
pleurisy evidence of slight tuberculosis. 

(6) Pain in chest and shoulders, night sweats, digestive disorders, 
etc., may be present and should be investigated. Fistula in ano 
should be considered as a tuberculosis manifestation, requiring care- 
ful examination of the lungs for traces of the disease. 

(7) In every doubtful case one should demand that the patient be 
kept under observation for at lease one month, with repeated sputum 
examinations, before a definite diagnosis is made. 

THE NATIONAL ASSOCIATION CLASSIFICATION 

(Modified by Dr. W. L. Rathburn) 

Lesions Symptoms 

Incipient. Slight infiltration A. (Slight or None). Slight or 

limited to the apex of one or no constitutional symptoms, 

both lungs, or a small part of including particularly gastric 

one lobe. No tuberculous com- or intestinal disturbance, or 

plications. rapid loss of weight; slight or 

Moderately advanced. Marked no elevation of temperature or 
infiltration, more extensive than acceleration of pulse at any 
under incipient, with little or tlme during the 24 hours. Ex- 
no evidence of cavity forma- pectoration usually small in 
tion. No serious tuberculous amount or absent. Tubercle 
complications. baccilli may be present or 

Far advanced Extensive local- B . a (Moderate). No. marked im- 

ized infiltration or consolida- p^irment of function, either 

tion in one or more lobes. Or local or const it u tional. 

£!^ nated n areas . of 5 a £ lty C. (Severe). Marked impairment 

zsszv&ssr tuber_ £n u ar tion ' locai and constitu - 

An incipient, moderately advanced, or far advanced case may 
have symptoms A, B, or C. 



163 









APPENDIX 



Standards of Treatment for Pulmonary Tuberculosis in Adults 

(1) Suspicious cases, etc. The majority of this group can be 
treated at home until they fall into Group 2 or 3. It should be made 
clear in every instance that the patient is on trial and that more 
radical measures, such as going to a sanatorium or elsewhere, may 
be and very likely will be necessary. In a few cases of this group, 
sanatorium or hospital treatment, if it can be obtained at once, is 
of great value educationally and otherwise and entirely justified in 
order to clear up a diagnosis in instances where adequate home 
treatment is not possible. 

(2) Cases in which the diagnosis is positive, and the disease active, 
with or without a positive sputum. Sanatorium or hospital treat- 
ment at once, and to be continued as long as the physician considers 
it necessary, is the ideal to be sought for in the great majority of 
cases. Home treatment may be substituted: 

(a) When there are no children in the family who might be 
exposed to the disease in the open form. 

(b) When the intelligence of the patient or the patient's family 
is such that adequate carrying out of details is possible. 

(c) When adequate nursing and medical supervision is available 
over a sufficiently long period of time. 

(d) When there are facilities at home for proper outdoor treat- 
ment under favorable hygienic surroundings. 

(3) Arrested and apparently arrested cases, discharged sanatorium 
cases, and those in whom the disease is inactive. Close medical and 
nursing supervision is essential in these cases, if the good done at 
the sanatorium is to be made permanent. There is no class of 
patients in whom hard work on the part of the physician and nurse 
will bring about better returns. Home treatment is naturally the best 
for the majority of these cases. How strict this should be in regard 
to outdoor sleeping, rest, etc., depends on the individual case. Fre- 
quent visits to the home by the nurse, and monthly examinations at 
the dispensary or doctor's office should be required. The amount of 
work done, and the choice of employment, are to be decided by the 
physician. 

It should be explained to the patient that it may become neces- 
sary at any time for him to return to the sanatorium or hospital on 
signs of an impending breakdown. 

Common sense, optimism, patience and tact, are essential factors 
in treatment. 

BIBLIOGRAPHY FOR THE PATIENT 
(A brief selection which the author found helpful) 
"Books are true levelers. They give to all who faithfully use them 
the society, the best and greatest of our race." 

(1) "What You Should Know About Tuberculosis," published by 
National Tuberculosis Association, 370 7th Ave., New York; price, 10c. 
A pamphlet of 32 pp. containing useful facts for the tuberculous and 
those living with them. 

(2) "Hints and Helps," by Dr. Chas. L. Minor, ex-Pres. Nat. 
Tub. Assoc'n. ; obtainable from this Association; price, 10c. 

(3) "Rules for Recovery from Tuberculosis," by Dr. Lawrason 
Brown; published by Lea and Febiger, Philadelphia, 1916; pp. 192; 
price, $1.50. An excellent little book, full of practical advice and 
detailed instructions. 

(4) "Tuberculosis: A Preventable and Curable Disease,'' by Dr. 
S. A. Knopf; Moffet Yard & Co., publishers, New York, 1919; pp. 



164 



APPENDIX 



382. Practical suggestions on factories, schools, churches, public 
libraries; many illustrations of sanatoria here and abroad; detailed 
advice. 

(5) "The Battle With Tuberculosis and How to Win It," by 
Dr. D. McD. King; published by Lippincott; price, $1.50; pp. 253. 
The author displays keen insight and understanding of human 
nature. An entertaining and highly figurative narrative of how to 
win the battle with tuberculosis. 

(6) "How to Live," by Irving Fisher and Eugene Lyman Fisk; 
published by Funk and Wagnalls Co., New York; 15th ed. ; pp. 324; 
price, $1.50 net. The title is a good index of the contents — rules for 
healthful living based on modern science. Air, food, clothing, 
poisons, alcohol, tobacco, hygiene, work, play, rest and every phase 
of life is considered. 

(7) "Fresh Air and How to Use It," by Dr. Thos. S. Carrington; 
published by the Nat. Tub. Assoc'n, 370 7th Ave., New York, 1912; 

pp. 241 ; price, . Practical suggestions with many illustrations 

and plans of sleeping porches, roof tents, open-air bungalows, etc. 

(8) "An Autobiography," by Dr. E. L. Trudeau; published by 
Doubleday Page and Co., Garden City, N. Y., 1916; pp. 322; price, 

,$2.00 net. A most interesting account of a busy, useful, and highly 
successful life handicapped by intermittently active tuberculosis for 
over forty years. 

(9) "Nostrums and Quackery," published by Am. Med. Assoc'n, 
535 N. Dearborn St., Chicago, 111. Complete exposure of patent 
medicines, quack, "consumptive cures," etc. 800 pp., 500 illustrations. 
Price, $2.00 postpaid. 

(10) "What Men Live By," by Dr. R. C. Cabot. Work, play, 
love, and religion are the dominant forces in man's life. Dr. Cabot 
analyzes these forces and shows their influence in one's life. 

(11) "Adventures in Contentment," by Dr. David Grayson; pub- 
lished by Grosset and Dunlop, New York, 1907; pp. 249; price, 60c. 

(12) "T. B. : Playing the Lone Game Consumption," by T. C. 
Galbreath; published by Journal of Outdoor Life Pub. Co., New 
York, 1915; pp. 80; price, 25c. Experiences and mistakes of a 
tuberculous patient interestingly and warningly set forth. 

(13) "The Great American Fraud," by Samuel Hopkins Adams; 
published by P. F. Collier and Sons, New York, 1907; pp. 150; 
price, . An exposure of patent medicine frauds. 

(14) "Consumptive Cures," published by Am. Med. Assoc'n, 
535 N. Dearborn St., Chicago; pp. 133; price, 35c. An exposure of 
patent medicine fakers. "The speciously worded advertisement, the 
exaggerated claims,, the favorable testimonials, all conspire to con- 
vince the consumptive that here at last is the long hoped for cure. 
Hence the profitableness of this most despicable branch of quackery." 

(15) "Tuberculosis Legislation in the United States''; a pamphlet 
of 63 pp. prepared by the Nat. Tub. Assoc'n; price, 10c. Gives 
summary of laws passed by different states. 

(16) "Journal of the Outdoor Life," 370 7th Ave., New York; 
a monthly journal devoted to the interests of tuberculous patients; 
price, $2.00 per year. Official organ of the National Tuberculosis 
Association. 

_ (17) List of sanatoria containing rates, location, condition of ad- 
mission, etc., may be obtained from "Journal of Outdoor Life," 
370 7th Ave., New York. 



165 



INDEX 



Adirondack Cottage Sanatorium, 
94, 136. 

School of Tuberculosis, 94. 
Adults, 24, 48, 50, 106. 
Advice, general, 36. 

pleasant vs. good, 31. 

of ex-patients and friends, 31. 

of physicians, 32. 

of ignoramus, 113. 

cheap, 33. 

concerning sanatorium, 33. 

concerning occupation, 35. 

on climate, 64. 
Age, preventive measures against 

old, 122. 
Air, 48, 63. 
Alcohol, 85, 115. 
Altitude and climate, 58 et seq. 

high, 60. 

low, 60, 
Amusements, 72. 
Animals, 97. 
Appetite, aid for, 67. 

medicine and, 85. 
Artemus Ward, 147. 
Artificial pneumothorax, 84, 96. 
Aurelius, Marcus, 41, 126, 133. 

B 
Babson, Roger, 151. 
Bag, paper, 66. 
Baldwin, E. R., 17, 139. 
Baths, 78. 
Bayle, 90. 
Bedding, 52. 
Bibliography, 164. 
Bichat, 151. 
Billiards, 72. 
Birds, 72. 
Bodington, 91. 
Books, 128, 164. 
Bowditch, 94. 
Bowels, 70. 
Brehmer, 93. 
Bronchi, 19. 
Brown, Lawrason, 76. 
Burns, John, 130. 
C 
Calory, 75. 
Carbohydrates, 74. 
Careless consumptive, 110. 
Caveat Doctor, 103. 
Charlatans, 118. 
Chateaubriand, 107. 
Children, 24, 50, 106. 

rights of, 112. 
Chopin, 107, 151. 
Christian Science, 119. 

limitations of, 120. 

opposition to hygienic mea- 
sures, 121. 



Climate and altitude, 58 et seq. 

ideal, 62. 

change of, 61. 

value of, 60, 63. 

advice on, 64. 
Clothing, 37. 
Colds, 37. 
Cornet, 92. 
Cough, 68, 38. 

after meals, 68. 

simple remedies for, 68. 

importance of control without 
drugs, 68. 
Cure, 55. 

period of, 56. 
Cures of patent medicines, 
quacks, etc., 118, 119. 
D 
Death rate, 12, 25, 53. 
Dettweiler, 93, 139. 
Diet (see Food), 72. 
Disease, preventive measures 

against, 122. 
Disinfection, 52. 
Dusting, 52. 

E 
Eating, 37, 75. 

overeating, 76. 
Eddy, Mrs., 119. 
Eggs, raw, 67. 
Egyptians, 89. 

mummies, 89. 
Emerson, 41. 
Emotions, 42, 43. 
Essentials, 61. 
Exercise, 82. 

danger of, 82. 

rules for, 82. 

F 
Fatigue, 37. 
Fats, 74. 
Fears, 107. 
Fever, 80. 
Flint, Austin, 95. 
Floors, how cleaned, 52. 
Fluegge, 93. 
Food, 72. 

importance of. 73. 

amount of, 75, 76. 

cost of, 159, 160. 

classification of, 74, 154. 
Food values, tables of, 155-158. 
Forlanini, 97. 
Fumigation, 52. 

G 
Galen, 90. 
Gain in weight, 75. 
Games, 72. 
Gerhardt, 94. 
Goebersdorf, 10*. 
G rancher, 138. 



166 



INDEX 



H 



Habitus phthisicus, 15. 
Healing of lungs, 22, 56. 
Health, 113, 119. 
Heart, 20. 
Heat, 48, 67. 
Heine, 151. 
Hemorrhage, 27. 
Heredity, 14. 

Historical survey, 89 et seq. 
Hippocrates, first to describe 
tuberculosis, 89. 

hippocratic oath, 99. 
House-keeping cottages, 62. 
Hoarseness, 28. 
Hobby, 72. 

I 
Ignorance, 105. 
Immunity, 14, 23. 
Infants, 24, 48, 50, 106. 
Infection, 11 et seq. 

when acquired, 11. 

how acquired, 13. 

primary, 13. 

man and wife, 16. 

prevention of, 47. 

congenital, 14. 

exposure to, 16. 

summary on, 17. 
Inheritance, 15. 
Insomnia, 71. 



Jackson, Andrew, 151. 
Job, 129. 

Jones, John Paul, 151. 
Journal of Outdoor Life, 165. 

K 
Keats, 151. 
Kerensky, 151. 
Knopf, 108. 
Koch, 23, 91. 

L 
Laennec, 90, 139. 
Lang, Anton, 151. 
Lanier, 129, 140. 
Loomis, Dr., 135. 
Lungs, anatomy of, 19. 

amount of blood and air 
handled by, 20. 

amount of 1. tissue necessary 
for life, 22. 

exchange of gases in, 19. 

healing of, 22. 
le Page, 151. 
Lyman, 111. 

M 
Mark Twain, 127. 
Mayo, W. J., 120. 
Medicine, 85. 

patent, 115. 



Milk, 51. 

pasteurized, 52. 
Moliere, 146. 
Morale, 39, et seq. 
Morton, 90. 

S. G., 94. 
Mouth, 71. 
Murphy, 97, 

N 
Napkins, paper, 66. 
National Tuberculosis Assoc, 

95. 
Night sweats, 28. 
O 
Oath, hippocratic, 99. 
Occupation, 35. 
Oils, 70. 

Open-air schools, 50. 
Osier, 108. 
)vereating, 76. 



Palmer, Alice Freeman, 125. 
Paper, bags and napkins, 66. 
Pasteur, 46. 
Patent medicine, 115. 

alcoholic contents of, 115. 
Patient, 100, 101. 
Physician, qualifications of, 100. 

confidence in, 101. 

candor, 102. 

co-operation with, 102. 
Pbthisiophobia, 105 et seq. 

evils of, 110. 
Pliny, 90. 
Pottenger, 103. 
Predisposition, 15. 
Prejudice, 109. 
Preventive measures, 51. 
Protein, 74. 
Pulse, 80. 
Pyorrhea, 71. 

Q 

Quimby, Dr., 120. 

R 

Races, 97. 
Raphael, 151. 

Reaction of patients on learning 
they have tuberculosis, 123 
Rectal temperature, 79. 
Relapse, 24. 
Religion, 41. 
Respiration, 20. 
Rest, 81. 

cough and, 68. 
Routine, daily, 77. 
Rush, 94. 

S 
Saranac Lake, 109. 



167 



INDEX 



Sanatorium, value of, 33, 34. 

first one established, 93. 

suitable cases for, 33. 
Sand, George, 107. 
Scar tissue, 21, 22. 
Schiller, 144. 
Self-control, 44. 
Serenity, 41. 
Signs of time, 122. 
Sleep, 71. 
Socrates, 128. 
Sources of infection, 49. 
Sputum, disposal of, 51. 

droplets, 93. 

dried, 92. 
Spinoza, 151. 

Standards for diagnosis, classi- 
fication and treatment of 
tuberculosis, 161. 
Statistics, 54, 61. 
Sterling, 151. 
Stern, 151. 

Stevenson, R. L., 127, 143. 
Suggestions, 66 et seq. 
Sunlight, 48. 
Sweeping, 52. 
Sylvius, 90. 
Symptoms of tuberculosis, 27. 

classification of, 28. 



Thoreau, 151. 
Timrod, 151. 
Tobacco, 87. 
Treatment, 55, 56, 164. 
Trudeau, 93, 108, 133-138. 

school of tuberculosis, 94. 
Tubercle bacilli, 18. 

types of, 98. 
Tuberculin, 23, 83, 96. 

as diagnostic agent, 97. 

dangers of, 83. 

treatment with, 83, 84. 
Tuberculosis, extent, 97. 

control of, 49. 

National Association. 95. 

nature of, 21 et seq. 

prevention of, 45 et seq. 

cure of, 55, 56. 

early symptoms of, 27. 

types of, 29. 

diagnosis of, 30, 161-164. 

classification of, 163. 

treatment of, 164. 

most dangerous periods, 12. 

progress in, 53. 
Twain, Mark, 127. 



U 



Underwear. 37. 



Tables, of weight, 152. 

of food values, 155-158. 

cost of food, 159. 

•of vitamins, 152, 153. 
Tanlac, 114. 
Teeth, 71. 

Temperaments and Tubercu- 
losis, 123. 
Temperature, 78. 

how and when to take, 79. 

mouth, 79. 

rectal, 79. 

normal, 78. 
Testimonials, 116. 



Ventilation, 48. 
Villemin, 91. 
Virchow, 91. 
Vitamins, 152, 153. 
von Behring, 93. 

W 
Ward, Artemus, 147. 
Water, 70. 

Weight, tables of, 152. 
Wesley, John, 149. 
Work, 35, 36. 
Worry, 40, 124. 
Wright, Harold Bell, 149. 



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